Expert Insights On Managing Traumatic Wounds
Important questions arise when traumatic wounds occur in the lower extremity. Accordingly, our expert panelists address key considerations in the initial evaluation and when one should consider an amputation. They also explore the use of soft tissue coverage, skin substitutes and topical dressings with traumatic wounds.
Q: What protocol/triage steps do you utilize in the initial evaluation of a traumatic wound?
A: For a patient with extreme pain and a traumatic wound that requires immediate surgical debridement, Molly Judge, DPM, says pain management and an expeditious transport to the operating room become paramount. She notes this is especially important in pediatric cases when the shock of the injury and unusual pain may require doing the initial survey of the patient on the operating table prior to prepping and draping.
If pain management is easily manageable in the emergency room, Dr. Judge and John McCord, DPM, perform a general survey of the patient to ensure there is no active bleeding or a secondary site of trauma that exists in less obvious areas of the extremity. Dr. Judge then begins a patient interview while inspecting the entire patient to identify all areas of injury. Dr. McCord also checks the patient’s vital signs for signs of shock and assesses his or her circulation.
A. Douglas Spitalny, DPM, says the initial OR visit primarily consists of incision and drainage. When it comes to assessing patients with traumatic wounds, Dr. Spitalny starts by assessing the depth and size of the wound, and the skin edges. He also determines if the wound is dirty. If there are any fractures, Dr. Spitalny assesses whether they are stable. He also determines if there is any joint involvement and what neurovascular structures are adjacent to the wound. For Dr. Judge, the ABCs for lower extremity trauma include identifying adequate perfusion to the limb; screen ing arterial supply by palpation or Doppler; and identifying bullae or blistering, which may suggest the presence of a fracture, impending wound or compartment syndrome. Finally, she says one should assess the temperature gradient of the limb for calor and erythema of an infected limb or the coolness and cyanotic hue of an ischemic limb.
Dr. Judge also suggests close inspection of the skin to identify the presence of unusual tension, ecchmyosis or trauma blisters, which may suggest fractures or dislocations in advance of ancillary imaging. One should subsequently obtain routine plain X-ray views, according to Drs. Judge and McCord. In addition to using X-rays, Dr. McCord says CT scans can help in locating foreign bodies.
Dr. Judge says manipulating the extremity to identify bone and joint injury includes ruling out unusual tension within muscle groups to ensure there is no impending compartment syndrome. Dr. McCord suggests using pressure testing to rule out compartment syndrome. Dr. Judge suggests performing a cursory inventory of epicritic sensorium in advance of surgery and following up later with a more thorough inventory to identify the level or reduced sensation when it exists.
As Dr. Judge notes, when evaluating a gunshot wound, it is not uncommon to find an exit wound elsewhere in the extremity. When that wound is in the posterior aspect of the leg or ankle, she says it often escapes the triage team in the trauma survey. When the patient is on a stretcher, Dr. Judge says one should roll over him or her to check for less obvious areas of injury as physicians can easily miss the presence of an open fracture on the posterior limb. Overlooking such a fracture results in inadequate treatment and would likely increase morbidity, emphasizes Dr. Judge. In such cases, she says intravenous antibiotics are therapeutic, not just prophylactic, and are required to minimize morbidity.
Unless the patient has a severe blast injury, Dr. Spitalny rarely considers an amputation. However, when in doubt, Dr. Spitalny will remove questionable tissue or bone. One should never leave dead bone fragments and cortical bone that is devoid of periosteum is useless, according to Dr. Spitalny. He adds that podiatric surgeons can always replace bone, make new bone or perform bone transport. Dr. Spitalny says the priority is removing all nonviable tissue.