Essential Insights On Managing Traumatic Wounds
- Volume 18 - Issue 9 - September 2005
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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.