How To Manage Traumatic Wounds Successfully

Clinical Editor: Lawrence Karlock, DPM
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.

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