Expert Insights On Managing Traumatic Wounds
Dr. Spitalny tries to determine whether a trauma patient needs an external fixator during the first OR trip.
He cites the Gustilo and Anderson Classification System and the Mangled Extremity Severity Scoring System (MESS) as the basis for analyzing and describing traumatic wounds. Although neither system is perfect, Dr. Spitalny says the MESS system can at least provide surgeons a baseline for determining salvage versus amputation.
Younger patients have a better chance of enduring a prolonged, reconstructive recovery and seem to recover even quicker from an amputation once they have accepted the emotional loss of their limb, according to Dr. Spitalny. On the other hand, he says older patients “seem to hate whichever route we take.” He frequently permits patients to choose their own path once their wounds are clean and fractures are stable.
“Despite the fact that so many podiatrists do not have trauma practices, we underestimate our ability in regard to triage wounds,” says Dr. Spitalny. “Who else knows more about salvaging diabetic wounds and infections better then we do? Traumatic wounds are no more difficult. Often podiatrists are more practical than other surgeons in knowing when not to salvage.”
Q: How do you manage soft tissue coverage in the acute traumatic wound?
A: Dr. Judge generally tries to use simple mechanical forms of wound coverage in the acute setting. As she notes, vessel loops and skin staples can quickly and easily draw wound edges together with minimal tension, and help prevent contracture of tissues during the first days following initial debridement.
“This is an area where I feel strongly that both trauma surgeons and plastic surgeons are often too trigger happy to cover a wound before the wound has declared itself,” says Dr. Spitalny.
Dr. Spitalny notes some surgeons apply skin grafts or full muscle grafts that “fail miserably” because the surrounding tissue dies. As he asserts, coverage is relative, whether it is simply applying VAC therapy (KCI) to promote granulation tissue or applying an Integra graft (Integra Life Sciences). He says a primary goal is addressing infection before one proceeds to wound coverage. As Dr. Spitalny clarifies, closure is the end goal and one should not misinterpret it for coverage as coverage of bone and/or tendon is more important in the early stages of surgery.
In the same vein, Dr. McCord does not attempt soft tissue coverage with acute trauma, noting the potential of swelling and abscess to occur over the first few days. With most traumatic wounds, he uses delayed closure.
Q: What guides your decision between foot amputation and limb salvage in the severe military type wound?
A: Dr. Spitalny recalls his time in Fort Bragg when he assessed patients with landmine injuries from Afghanistan who had received initial treatment before presenting to him for salvage.
A lack of plantar skin coverage discourages Dr. Spitalny from salvage. He says plantar skin grafting faces recurrent breakdown for years to come. While free muscle grafting can absorb some shock, he notes it is just as likely to break down and often prevents patients from wearing regular shoes for years until the graft shrinks.
A lack of Achilles/calcaneal coverage is another factor in Dr. Spitalny’s salvage decisions. He notes that similar to the plantar foot, this area is difficult to deal with as reconstructing a deficient Achilles is not only challenging but rarely successful in regard to restoring normal strength and gait.
As for the loss of two or more toes, Dr. Spitalny notes the remaining toes in young, healthy individuals will hammer, drift and eventually become clawed. Rather than leave a patient with two toes, he will steer patients toward a transmetatarsal amputation.
When there is significant bone loss in the midfoot, Dr. Spitalny says if the patient has an unstable medial or lateral column that requires significant bone grafting and multiple fusions, the patient will need a spanning ex-fix for a long period of time as well as multiple surgeries to graft and restore the midfoot. With these patients, he considers advocating a below knee amputation.