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.
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.
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.
Crush injuries, as well as anything to do with motorcycle injuries, are Dr. McCord’s most challenging traumatic wounds. He cites a 16-year-old patient who went down in a motorcross race when another motorcycle slammed down on his foot and ankle. He had six fractures plus soft tissue trauma but no lacerations, and the foot had all of the characteristics of an explosive injury. As Dr. McCord says, the patient is finally doing well and is in physical therapy to regain range of motion and strength. He has also regained sensation that had been lost for three weeks.
An important aspect of treating trauma is getting a good history and understanding the physics of the injury, according to Dr. McCord. To understand the extent of the injury, he says DPMs need to remember the old physical formula of F=ma (force equals mass times acceleration).
Dr. Spitalny tries not to utilize topical dressings with traumatic wounds. He notes that he only uses VAC therapy with silver dressings such as Xeroform, Adaptic or Mepitel. He confesses to being “old fashioned” in that he will pack contaminated wounds with Betadine soaked gauze.
For Dr. Judge, non-adherent superficial dressings are the hallmark for traumatic wounds and one may subsequently apply sterile compression dressings as appropriate.
Dr. Judge is a Fellow of the American College of Foot and Ankle Surgeons. She completed a three-year surgical residency program in major reconstructive surgery for the leg, foot and ankle. She is board-certified in reconstructive rearfoot and ankle surgery. She has offices in Port Clinton, Ohio and Lambertville, Mich.
Dr. McCord is a Diplomate with the American Board of Podiatric Surgery. He practices at the Centralia Medical Center in Centralia, Wash.
Dr. Spitalny is a staff podiatrist at St. Mary’s Duluth Clinic in Duluth, Minn. He is a Fellow of the American College of Foot and Ankle Surgeons and a Diplomate of the American Board of Podiatric Surgery.
Dr. Karlock is a Fellow of the American College of Foot and Ankle Surgeons, and practices in Austintown, Ohio. He is the Clinical Instructor of the Western Reserve Podiatric Residency Program in Youngstown, Ohio. Dr. Karlock is a member of the Editorial Advisory Board for WOUNDS, a Compendium of Clinical Research and Practice.