Essential Insights On Managing Traumatic Wounds
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.
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