How To Manage Traumatic Wounds Successfully
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.