male gardener of African origin presented with increasing pain and
swelling of his left (non-dominant) thumb two weeks after a thorn
prick injury. Examination showed an infected and necrotic pulp space
with no clinical or radiological evidence of osteomyelitis.
skin and fat were debrided at two short-spaced procedures. This left
the patient with a large defect in the thumb pulp measuring 2 x
1.5 cm (Fig. 1) with exposed flexor pollicis longus insertion.
the debridement procedures, once the wound was observed to be clean,
a vacuum-assisted closure foam was cut to adjust the size of the
defect and applied with an airtight dressing (Fig. 2). The suction
tube of the dressing was connected to the pump for a total
period of four days with continuous application of a negative
pressure of 100 mmHg.
proliferation of healthy granulation tissues was noticed at the base
of the wound, filling the defect and covering the exposed tendon. The
wound was subsequently dressed with a non-sticky,
moist dressing to allow epithelialization and mobilization exercises
were continued during the whole process. Two weeks after the initial
treatment, good functional and cosmetic results (Fig. 3) were
observed. The sensory recovery was 2 mm of moving two-point
discrimination and the range of movement was full at the interphalangeal joint.
Closure (VAC), also known as negative wound pressure therapy, is
a modern technique designed to induce and promote wound healing.
The technique is based on defined, controlled negative pressure
application via foam dressing to wound surfaces. The vacuum system
encourages faster granulation tissue formation, removal of excessive
exudates, enhanced blood flow in the wound and attraction of the
borders of the wound to the centre (2). The technique has been
successfully used in the treatment of various types of soft tissue
injuries including degloving injuries, infected sternotomy wounds,
and various soft tissue injuries prior to surgical closure, grafting
or reconstructive surgery (1).
practice of exposing a wound to sub-atmospheric pressure to
promote debridement and healing was first described following the
successful use of this technique in patients with open fractures (3).
Over the following years, the technique acquired a good
reputation in the management of acute and chronic wounds including
pressure sores, diabetic ulcers, venous ulcers, surgical traumatic
wounds and radiated wounds.
range of procedures is currently used to treat digital pulp defects.
Depending on the extent of the defect, treatment can vary from
dressings with healing by secondary intention to split- or
full-thickness graft, cross finger flap, homodigital flap, thenar
flap, neurovascular flap or even toe pulp transfer (4).
to other conventional methods used in wound management, the
advantages of vacuum-assisted closure therapy include rapid wound
healing and reduced pain. The Minivac apparatus with which the
patient can be discharged home has further advantage of shorter
hospital stays, lower medical costs and fewer nursing
responsibilities (6). Complications associated with VAC therapy have
been minor and largely technical in nature. Erosion of surrounding
tissue, maceration of skin, excessive in-growth of granulation tissue
into the foam dressing, and pain are among the most common
complications found with this therapy (5).
this article, we described our initial experience with the VAC
therapy in treating thumb pulp defects. This had a satisfactory
outcome. To our knowledge, this is the first report in literature
describing the use of vacuum-assisted closure therapy for this
purpose. We propose this technique for the management of digital pulp
Hama Attar MRCS
Hale End Road
1. Avery C., Pereira J., Moody A., Whitworth I. Clinical experience with the negative pressure wound dressing. Br. J. Oral Maxillofac. Surg., 38, 2000, p. 343–345.
2. Ferreira MC., Wada A., Tuma JP. The vacuum assisted closure of complex wounds: report of 3 cases. Rev. Hosp. Clin. Fac. Med. Sao Paulo, 58, 2003, p. 227–230.
3. Fleischmann W., Strecker W., Bombelli M., Kinzl L. Vacuum sealing as treatment of soft tissue damage in open fractures. Unfallchirurg, 96, 1993, p. 488–492.
4. Guelmi K., Barbato B., Maladry D., Mitz V., Lemerle JP. Reconstruction of digital pulp by pulp tissue transfer of the toe. Apropos of 15 cases. Rev. Chir. Orthop. Reparatrice. Appar. Mot., 82, 1996, p. 446–452.
5. Susan ME. Negative pressure wound therapy. Plast. Surg. Nurs., 18, 1998, p. 27–35.
6. Tzeng YJ., Hung CC., Hsieh YM., Han CY. Using vacuum-assisted closure (VAC) in wound management. Hu. Li. Za. Zhi., 51, 2004, p. 79–83.