Expert Insights On Managing Traumatic Wounds
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.
For Dr. McCord, the decision for amputation depends on tissue viability and the potential for bone stability, with another factor being the patient’s general condition. In some cases, he says the best opportunity to return to function is amputation and prosthesis.
Limb salvage requires both a competent immune system and a competent vascular compartment to heal local wounds and eradicate infection, according to Dr. Judge. For a patient with peripheral vascular disease or an otherwise dysvascular limb, the question of whether the limb is salvageable is important. She will generally work with the input of the vascular trauma team to make this decision. When trauma has caused the devitalization of a large region of the extremity and the patient has other comorbidities such as sepsis, end-stage renal disease or acute and severe cardiovascular issues, she says amputation “may be the better part of valor” to abate the added morbidity from the lower extremity injury. In other words, her decision naturally favors life over limb.
Q: Is there any role for advanced skin substitutes or negative pressure closure in these cases?
A: When it comes to covering bone or tendon, Dr. Spitalny will use Integra (Integra Life Sciences). He says Graft Jacket (Wright Medical) can fill in deep wounds and tendon defects, and one can utilize this modality with antibiotic beads. While Mediskin, Integra and Graft Jacket can produce granulation tissue, Dr. Spitalny cites Apilgraf (Organogenesis) and Oasis (Healthpoint) as the best modalities for promoting epithelialization. In contrast, Dr. McCord has not found skin substitutes to be very useful.
Dr. Spitalny usually uses VAC therapy with all skin substitutes to promote adherence and fill in wound depth. Dr. Judge acknowledges the benefit of using negative pressure early in the management of traumatic wounds. In the case of a severe crush injury, she says it is prudent to delay such therapy to allow soft tissue and muscular elements to stabilize. As she says, one cannot understate the importance of permitting the extremity to recover properly from the shock that trauma imposes on the soft tissue, bone and neurovascular elements. Dr. McCord has found negative pressure to be “very useful.”
Ischemia and wound necrosis often occur days after the initial trauma so Dr. Judge says close monitoring during admission is required. In addition, she says necrotizing infections may spread up the limb swiftly with necrotic change occurring in hours rather than days. When one suspects necrotizing fasciitis, she says one should be able to undress the wound easily for inspection multiple times a day. In some cases, Dr. Spitalny says partial thickness skin grafting is better than a skin substitute and is his first choice to get epithelialization. He says he will wait a couple of weeks for this to occur.
“Surgeons frequently rush to get closure (not coverage) and forget that they need to do definitive fracture care and will end up having to disrupt their grafts to put in hardware,” explains Dr. Spitalny. “Experience has taught me to wait on closure. That is why I utilize so much external fixation.”
Q: Do you have any insights into the management of traumatic wounds with topical dressings?
A: Dr. McCord supports topical dressings if they are not causing harm, trapping abscess or pulling away healing cells. As he says, the most important role of a topical dressing is creating a more normal pressure gradient against the wound. He often uses Unna paste bandages for patients with tissue breakdown due to fracture blisters.