In a follow-up column to the previous discussion of lower extremity traumatic wounds (see “Essential Insights On Managing Traumatic Wounds,” page 32, September issue), the panelists discuss key principles in treating open fracture wounds in the forefoot and toes. They also share their thoughts on the use of plastic surgery techniques and advanced wound closure modalities. Without further delay, here is what the panelists had to say.
Q: How do you manage simple open fracture wounds in the forefoot/toes?
A: A. Douglas Spitalny, DPM, points out the so-called simpler fractures of the forefoot and toes have had the highest infection rate and long-term sequelae as a group. He has seen many cases of post-injury gangrene. He notes that surgeons often forget to treat nail plate and nail bed injuries as open fractures. Dr. Spitalny adds that open digital and forefoot fractures seem to have a much higher rate of post-traumatic pain.
He says stump neuromas, degenerative joint disease, the development of digital contractures, adhesive capsulitis, tendonitis, painful scars, fibromas, nonunions and/or malunions all seem to occur more frequently than reported.
“Although we tend not to manage these simpler cases in a formal OR setting, I do think these injuries are often overlooked and are still deserving of a formal wash out even in the ER or clinic,” explains Dr. Spitalny. “The principles of managing these injuries should remain the same regardless of location.”
Dr. Spitalny notes he has always worked in a hospital system that accepts open fractures as open injuries regardless of size and location. He is often able to wash out the wound in the ER, provide some temporary relief and discuss the need for a formal surgical debridement in the operating room the same day. Then he will develop a game plan for follow-up debridement and/or consultations.
When treating open fractures, Jordan Grossman, DPM, suggests evaluating the mechanism of injury, the circumstances contributing to bacterial contamination, the extent of soft tissue destruction and loss of function. The treatment goals should include preventing infection, restoring function and providing adequate soft tissue coverage, according to Dr. Grossman. He emphasizes prompt operative intervention with copious irrigation and excisional debridement.
When it comes to managing minimally displaced open fractures, such as phalangeal fractures and distal tuft fractures, Dr. Grossman says one may use primary closure and immobilization. He says primary closure is only indicated in clean wounds with no extensive tissue loss. While open fractures of the phalanges are not common, Lawrence DiDomenico, DPM, says one will see these fractures more often with crush injuries. He adds that toe fractures are the most common osseous injury to the forefoot. Since great toe fractures differ both functionally and anatomically, Dr. DiDomenico says one must recognize and consider the soft tissue attachments.
A fracture of the proximal phalanx of the fifth toe, which is also called “the night walker fracture,” is particularly common, according to Dr. DiDomenico. He says the injury results from direct trauma or stubbing the toe.
In the case of obvious radiographic deformity such as rotational malalignment or displacement, Dr. DiDomenico says one should perform reduction under anesthesia with either open or closed techniques based on the extent of the deformity. Post-op care entails a short leg walking cast or a hard-soled shoe for four to six weeks. He points out that malalignment and neglect can lead to painful prominences.
When it comes to more extensive comminuted or crush injuries of multiple digits and metatarsals, Dr. Grossman says it is frequently better to pursue temporary stabilization with K-wires or mini-external fixators, which can maintain length in the face of bone loss and severe comminution. Employing temporary fixation should achieve stability and minimize both dissection and further soft tissue insult, according to Dr. Grossman. While it is crucial to manage these wounds aggressively, Dr. Grossman says surgeons should delay definitive internal fixation until they have adequately recovered the soft tissues and the threat of infection is low. In regard to devitalized digits, Dr. Grossman says one may proceed to perform a primary amputation. In some cases, he notes surgeons may reserve the soft tissue envelope for subsequent flap coverage.
Dr. Grossman emphasizes that a higher degree of soft tissue injury traditionally carries a worse prognosis for the patient. He says these injuries often lead to amputation as well as prolonged recovery and rehabilitation. In cases of partial thickness skin loss, Dr. Grossman notes one should facilitate healing via secondary intention and grafting. He adds that oral antibiotics may or may not be required, depending on the extent of the injury.
Q: When do you utilize plastic surgery/advanced wound closure techniques? What type of techniques do you use?
A: Dr. Grossman suggests closing wounds with plastic surgery when faced with inadequate soft tissue coverage over exposed granulating bone, tendon or hardware. Surgeons should perform primary closure when a wound shows no signs of infection, is pink and healthy, and has properties of elasticity to allow for closure, advises Dr. DiDomenico. One should handle tissues gently and reapproximate the closure of deep layers anatomically in order to remove tension from the skin.
The recipient site of partial or full thickness skin grafts must have sufficient vascularity to support a good base of granulation tissue, point out Drs. DiDomenico and Grossman. They note that exposed tendon, bone and cartilage lacking a good base of granulation will typically not support a graft. Dr. DiDomenico says one usually employs such grafts to cover burn wounds, ulcerations and a loss of soft tissue. While wounds on the dorsum of the foot overlying a relatively thin subcutaneous layer respond well to grafts, Dr. Grossman cautions that plantar wounds are more subject to shear forces and split thickness grafts are often unable to withstand the forces required by prolonged weightbearing.
Dr. DiDomenico suggests using artificial grafts briefly to function as a biological dressing and a barrier. He adds that one can use bioengineered skin graft techniques for more chronic wounds. However, Dr. DiDomenico says such wounds must have a good base of granulation and not exhibit any signs of infection or significant drainage in order for good healing to occur.
Although it is not difficult to use local flaps such as rotational flaps, V-Y flaps and multiple Z-plasties, Dr. Grossman says these are limited to covering small defects. He points out that local flaps are contraindicated in acute trauma since their quality is compromised when surrounding tissue damage has occurred. Surgeons should reserve free tissue transfers and local flaps for large deficits with extensive soft tissue loss and exposed bone, according to Dr. Grossman. Even when the surgeon performs free flaps successfully, he says there may be significant long term struggles with shearing, callus formation, prolonged edema, loss of muscle function and the need for bracing and accommodative shoegear. Dr. Grossman says DPMs should consult a plastic surgeon for complicated wound closures and reconstructions.
While he notes he is not adept with plastic surgery techniques, Dr. Spitalny will not hesitate to consult a plastic surgeon but does not turn cases over to the plastic surgeon.
“Plastic surgeons are excellent consultants but we are far more capable of managing foot and ankle wounds,” emphasizes Dr. Spitalny. “If they know you are capable of managing such wounds, I assure you they will send it your way.”
Dr. Spitalny says he will ask for a plastic surgeon’s assistance on a free muscle graft or rotational flap. However, he does not see much value in plastic surgery until wounds are clean and viable and fractures have been stabilized. He adds that rotational flaps, skin expanders or even skin grafts have little place early in treatment.
However, Dr. Spitalny emphasizes that the early use of negative pressure wound therapy (VAC, KCI) has “simply revolutionized trauma surgery.” Lawrence Karlock, DPM, concurs about the efficacy of the VAC, saying it promotes granulation tissue over deep exposed tendon and allows for more definitive coverage of soft tissue.
Dr. DiDomenico is a Fellow and member of the Board of Directors of the American College of Foot and Ankle Surgeons. He is a Diplomate of the American Board of Podiatric Surgery and an Adjunct Professor at the Ohio College of Podiatric Medicine. He is the Director of the Reconstructive Rearfoot & Ankle Surgical Fellowship at the Ankle and Foot Care Centers at the Ohio College of Podiatric Medicine.
Dr. Grossman is Chief of the Section of Podiatry at the Akron Medical Center in Akron, Ohio. He is a Fellow of the American College of Foot and Ankle Surgeons and a Diplomate of the American Board of Podiatric Surgery.
Dr. Spitalny is a staff podiatrist at St. Mary’s Duluth Clinic in Duluth, Minn. He is a Fellow of the American College of Foot and Ankle Surgeons and a Diplomate of the American Board of Podiatric Surgery.
Dr. Karlock (pictured) is a Fellow of the American College of Foot and Ankle Surgeons, and practices in Austintown, Ohio. He is a member of the Editorial Advisory Board for WOUNDS, a Compendium of Clinical Research and Practice.
Editor’s note: For the first part of this discussion, please see the September 2005 issue or check out the archives at www.podiatrytoday.com.