One Surgeon's Point of View on Trauma Principles

Hello everybody, and welcome back to Podiatry Today Podcasts, where we bring you the latest in foot and ankle medicine and surgery from leaders in the field. We're lucky enough to have Dr. Ali Rahnama back with us one more time. He's a fellowship-trained foot-and-ankle surgeon at the MedStar Washington Hospital Center in Georgetown University Hospital, and he's here to speak to us today a little bit about some general trauma principles.

I'm Dr. Jennifer Spector, the Assistant Editorial Director for Podiatry Today, and we're thrilled to bring you this particular episode.

So for newer surgeons or those who haven't typically seen as much trauma in their practices, what do you feel are the most important principles to keep in mind when approaching these cases?

Ali Rahnama, DPM:

I think a lot of times when having these discussions, so much of the emphasis and the focus is on how to address a particular pathology, and that's great. Even myself personally, I utilize so much of that and try to take in as much of that knowledge and other people's experience as possible. But I think a really important thing that a lot of times maybe we don't talk about is when not to address or when not to operate on a patient. And I think a lot of this goes into, if you don't feel 100% absolutely comfortable with a particular pathology, and if you don't 100% absolutely feel comfortable with the appropriate ways to have to tackle sometimes a pathology, then just stay away from it.

If you say, "I'm really good at just lateral and medial approach to the ankle, but I'm not so comfortable, or I don't do a whole lot of anterolateral approach for the distal tibia. I'm not used to doing posterolateral approach to the distal posterior fibula and the distal posterior tibia," well, then you probably shouldn't be addressing or trying to tackle that smashed pilon that's going to require multiple incisional approaches for you to be able to really do the patient well, so pass it off.

A lot of times, I think some folks will maybe try to address parts of the injury or the pathology that they feel comfortable and then pass off the rest and try to be a helper, so to speak. If you're not going to do the pilon or IF, if you're not going to adjust the distal tibia, don't try to take care of the fibula fracture that's associated with it. Put the patient in a frame. Package them up. Call your trauma colleague, whoever that might be in your community, or even if it's another one of the partners in your own practice, just give them a call and just pass it off.

And I'd say that's probably the number one biggest thing that I would tell folks, particularly early on, because you don't want to get a reputation for being the guy who's a cowboy and just takes on anything. You want to have the reputation as the guy who does good-quality work and knows what they do well, because no one person is going to be able to handle everything and every pathology that walks in through their office. That's just the reality of it. That's probably the biggest pearl that I would have for folks.

Jennifer Spector, DPM:

And chances are, that colleague that you're referring to is also going to get to know you and what you like to do, and there's probably a reciprocal relationship available there where you are passing off cases that they're the most enthusiastic about and they're exchanging you cases that you are going to really enjoy and do well with as well. So it can work both ways.

Ali Rahnama, DPM:

Absolutely. Absolutely agreed. And even in our own little practice that we have here in Washington with my partners and I, we all have things that we like. I like the trauma stuff. They kick that to me. But if I have a patient who is really asking for a total ankle, I send them to my other partner who does them in volume. It just makes more sense. Could I do that case? Sure, but would you want somebody to do that for you who does a lot of them or just maybe does one a year? And the reality of it is if it's my brother, my dad, uncle, whatever, I want them going to the guy who does it in volume and does a lot of them. And so it is just the best thing for the patients, and that's what it ultimately comes down to is patient care.

Jennifer Spector, DPM:

It's always a sound way of making decisions when it comes to the surgical approach, but assuming that you do feel comfortable and you're in this particular area of trauma, can you talk a little bit about how a surgeon determines whether or not that particular case requires operative intervention or if non-operative treatment is most indicated?

Ali Rahnama, DPM:

Yeah. I think ultimately, that comes down to... I think what you're trying to say is not every case is always going to be clear-cut, and not every X-ray or MRI or CT even is going to tell you, "Oh, unstable injury, it needs to go." What I would tell you is that if you're on the fence, most ankle or midfoot injuries, you can utilize stress radiography in the clinic space, even. If you're on the fence about a distal fibula, but it looks almost completely perfect, there's no diastasis, there's no gapping, stress it. The same thing can go if you have a subtle midfoot injury. Is this a true Lisfranc or is this just a partial tear sprain? Stress it.

And if that's negative and you're doing weight-bearing bilateral X-rays and so on and so forth, and you're on the fence, get your advanced imaging. Always stick to your principles and stick to the basics, and if you just utilize that for every single patient you see and every single pathology you see, traumatic or otherwise, I think you're always going to do what's right, and ultimately, your decision-making will be guided by that.

Jennifer Spector, DPM:

Are there ever any patient-related factors that might come into play in that decision-making? Perhaps somebody that's not a great surgical candidate in something that is borderline stable, or their ambulatory status? Do those ever come into the decision-making process?

Ali Rahnama, DPM:

Sure. Absolutely. Yeah. If I have a patient who's just not a good surgical candidate for one reason or another, then oftentimes I'll say, "You know what? We're going to cast-immobilize this. I'm going to follow you very closely, even if that means I have to see you every other week or even weekly or something like that, just to make sure that you're doing all right, and let's double our, let's say, non-weightbearing time. Let's make sure we're keeping you off of this for a long enough period, and we'll continue to get serial radiographs in the office to make sure that we didn't lose that reduction or that it's now becoming grossly unstable, whether it's in the ankle or the hind foot or whatever it may be that we're dealing with."

I think there's nothing wrong for doing that. I think you always want to make the decision that other folks would make. And to that point, it's never wrong to also pull your colleagues. Ask friends. Make sure you're doing it in a HIPAA-safe fashion, but send your X-rays or send your imaging and the clinical scenario to friends and colleagues and old classmates or co-residents and make sure that you're all on the same page. "Hey guys, I don't think I'm going to operate on this one. Here's X, Y, or Z. Here's the reason." Or, "I do think I'm going to operate on this one for X, Y, or Z reason." And make sure that other folks agree with you, that you know trust and whose opinion you respect.

Jennifer Spector, DPM:

So are there any trauma cases that you've encountered over the years that have been particularly impactful or particularly challenging that you feel have really informed the way you practice today?

Ali Rahnama, DPM:

Okay, I have one. All right. So one of the cases that stuck out with me was this younger, 30-something-year-old gentleman who came to see me, probably when I first got out of training and into practice. He had previously had a crush injury to his forefoot with an open proximal phalanx fracture of his great toe, and had been treated by another surgeon in an orthopedic group in a different state.

He had what he was describing to me that sounded like chronic osteomyelitis, and there was some cortical change on the X-rays and the hardware still intact, but he was describing the scenario where, "Every couple of months it comes to a head and I get some of this drainage, and then it feels like it relieves and then it heals, and then I cycle through again."

So we took the patient, we did a hardware removal, we biopsied and cultured everything, and the cultures came back negative, but the pathology came back concerning for possible osteomyelitis. So we did a resection and we did a distraction bone-block arthrodesis of his interphalangeal joint with new hardware and everything looked great, but he continued to have so much pain. And trying to just get him to my pain colleagues and just trying to do something... And just bad injury, not a whole lot of soft tissue, not a whole lot of bone and real estate to deal with.

And radiographically, I think the outcome looked acceptable. I think it looked good given the injury that he had, but it's just to respect these injuries regardless of the part of the anatomy. You might just think, "Oh, well, that's a great toe fracture." To that guy, it's no different than the worst distal tibia or plateau or femur, whatever you have. For him, it was debilitating and it continued to be debilitating, and it was just one problem after another, and he just wanted to get back to work.

And so I feel like that case really left me just respecting these traumatic injuries, regardless of the anatomy, regardless of how, "Oh, that's just a toe." No, that's a part of somebody. That's their livelihood. That's their life. It's their quality of life. So that case always sticks with me, and thinking of ways to just always give it your all and always try to do what's best for the patient, and then do as best of a job as you can, and that's all you can do.

Jennifer Spector, DPM:

Well, thanks again, Dr. Rahnama, for sharing your insights with us on trauma. I'm sure there's going to be even more to talk about in future episodes, so we hope you'll join us again and we hope the audience will join us again for future and past episodes that you can find on Podiatry Today Podcasts, SoundCloud, Spotify, Apple Podcasts, or your favorite podcast platforms.