Traumatic injuries in the lower extremity can be particularly difficult to manage and treat. Not only is it difficult to assess the degree of the damage caused by these injuries, prompt evaluation and treatment is essential given the risks of infection and amputation. With that said, our expert panelists review their treatment protocols.
Q: What are the basic guidelines/philosophies in treating lower extremity traumatic wounds?
A: Jordan Grossman, DPM, emphasizes precise evaluation of the clinical and radiographic presentation. Lawrence DiDomenico, DPM, says it is essential to perform an initial, thorough neurovascular and musculoskeletal exam. Dr. Grossman concurs, pointing out that the extent of soft tissue damage is “frequently underestimated” in traumatic injuries. One should thoroughly inspect all anatomical landmarks within that zone of injury, according to A. Douglas Spitalny, DPM. He says the zone of injury is “always greater than expected.
“It is always amazing to see which nerves, arteries or tendons were spared and which structures were damaged,” notes Dr. Spitalny.
Dr. Grossman says early surgical intervention and early IV antibiotics are the two most important tenets of managing traumatic wounds. One should proceed with initial irrigation and urgent debridement as soon as possible, according to Dr. DiDomenico. He says one should obtain a tetanus history and institute broad spectrum antibiotics depending upon the wound type (and pending culture results). Drs. DiDomenico and Grossman encourage surgeons to utilize serial debridement and pulsatile lavage until they have removed all necrotic and devitalized tissues, and the wound bed appears clean and viable.
One should be cautious though about assuming a wound is clean, warns Dr. Spitalny. He notes that clinicians often assume a skin edge is viable and it becomes dusky.
“We have all seen our diabetic wounds and infections go south,” explains Dr. Spitalny. “We forget the same can happen with open fractures even in the healthiest of patients.”
Accordingly, Dr. Spitalny says definitive fracture reduction is neither necessary nor prudent early. Dr. Grossman concurs, noting that he will often delay definitive stabilization and closure until inflammation begins to subside and the infection has been properly managed.
In terms of treatment, Dr. Spitalny says he tends to shy away from early use of AO fixation. He prefers to utilize smooth K-wires whenever possible and opts for external fixation as his first line of treatment for unstable fracture patterns, bone defects, significant soft tissue loss and/or intraarticular injuries. Dr. Spitalny says a variety of external fixation systems are available in terms of size, strength and flexibility. He says there are enough systems out there that can provide the capability to manage the traumatic injury early. Dr. Spitalny adds that many of these ex-fix systems can be “easily converted” into a stable and definitive fixation alternative to internal fixation regardless of size or location.
Good internal or external fixation is “mandatory” to facilitate bony union and allow for adequate treatment of soft tissue injuries, according to Dr. DiDomenico. He says one may need to perform soft tissue debridement every 24 to 48 hours as needed to ensure optimal wound management. Dr. Spitalny agrees this is probably the biggest mistake surgeons make, saying multiple surgical visits are critical to prepare the wound for closure, skin grafting, fixation and/or bone grafting. Dr. DiDomenico notes bone grafting is often needed to fill defects when there is extensive bone loss. He says surgeons should leave these wounds open to facilitate delayed primary closure, skin grafting or plastic reconstruction. Dr. Spitalny adds that some wounds may require antibiotic beads or spacers during this transitional period.
Q: How do you manage complex lawnmower injuries of the foot?
A: “These are grossly contaminated and tragic injuries that often lead to disfigured and debilitating feet,” emphasizes Dr. Spitalny.
Lawnmower and farm-related injuries are often traumatic penetrating injuries, according to Dr. Grossman. He says these injuries have “significant morbidity due to the prevalence of polymicrobial infection and significant soft tissue loss.” Dr. DiDomenico notes these injuries are often amputations as opposed to simple fractures, and adds that most traumatic lawnmower-related injuries result in terminal amputations.
The panelists agree one should initially perform appropriate irrigation and debride the wound as soon as possible.
Dr. DiDomenico says surgeons should proceed to follow the same principles of open fracture management with these injuries. Drs. DiDomenico and Grossman agree that this entails a thorough clinical exam (including a neurovascular and musculoskeletal evaluation), appropriate tetanus prophylaxis and antibiotic therapy.
Clinicians should be careful to limit wound exposure prior to performing operative debridement, notes Dr. Grossman, who notes the risk of cross-contamination in the emergency room environment.
“Due to the deep, penetrating nature of these injuries, contamination with grass, soil and other particulate matter raises suspicion of anaerobic infection,” explains Dr. Grossman.
Accordingly, he recommends broad-spectrum antibiotic coverage with the addition of penicillin to ward off clostridial organisms. Dr. Spitalny advises clinicians to obtain an infectious disease consult.
Given the typically high degree of contamination with such wounds, Dr. DiDomenico notes soft tissue injuries should “never be primarily closed” and says obtaining quantitative wound cultures can be beneficial in assessing the degree of contamination.
Dr. DiDomenico strongly emphasizes careful handling of soft tissues with these injuries. Dr. Grossman concurs.
“Often, the clinical appearance masks the greater degree of underlying soft tissue damage,” points out Dr. Grossman. “Often, the extent of tissue devitalization continues to demarcate well beyond the initial injury. For this reason, emergent operative exploration is necessary.”
Dr. DiDomenico says managing the soft tissue loss is very challenging. He explains that surgeons must assess the viability of the remaining adjacent tissues and make decisions about the exposed bone, ligaments and tendon (i.e., bone debridement and resection or some sort of coverage) in order to minimize desiccation of these structures. One should take care to preserve all viable muscle and tissue for later reconstruction and flap coverage when necessary, according to Dr. Grossman. Dr. Spitalny says it is helpful to obtain a plastic surgery consult.
Dr. Grossman notes surgeons may pursue temporary stabilization via external fixators or use simple K-wires to maintain length and position. When it comes to comminuted fracture fragments stripped of their blood supply and inadequate soft tissue coverage, Dr. DiDomenico says external fixation is “often an excellent alternative treatment.”
In regard to definitive reconstruction and closure (including bone grafting and internal fixation), Dr. Grossman implores surgeons first to ensure the infection has been eradicated and there is no remaining necrotic tissue before initiating these procedures.
When addressing injuries that are confined to the digits and distal forefoot, Dr. Grossman says surgeons can often manage these injuries with primary closure after performing the initial irrigation and debridement. He notes these injuries carry significantly less morbidity and one can generally achieve a prompt and satisfactory functional result.
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.
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.
Dr. Grossman is Chief of the Section of Podiatry at Akron General Medical Center in 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.
Editor’s Note: The second part of this discussion on traumatic injuries in the lower extremity will appear in the November issue of Podiatry Today.