How To Treat Traumatic Wounds In The Lower Extremity

As patients go barefoot in the summer, they can step on glass or other debris. These expert panelists expound on treating puncture wounds and other trauma wounds such as skin lacerations and burns.

Q:

What is your approach to lower extremity puncture wounds, such as wounds caused by stepping on nails and broken glass?

A:

Lawrence Karlock, DPM, advocates expedient evaluation and treatment of puncture wounds in the foot.

“These wounds can notoriously lead to osteomyelitis and even limb loss in the high-risk foot type,” emphasizes Dr. Karlock.

As with any other wound, Kazu Suzuki, DPM, CWS, begins by taking a good history to identify the severity of injury, the depth of wound penetration and if deeper structures (joint or bone) were penetrated. His clinic offers a booster tetanus shot if patients have not had it within 10 years or if patients cannot recall when they had their last shot. Dr. Karlock also advises giving tetanus prophylaxis and empirical antibiotics.

For a penetrating wound due to stepping on a nail, Dr. Suzuki may block the wounded area with local anesthetic, make an incision directly over the puncture hole, try to irrigate it with saline and decontaminate the wound as much as possible. Dr. Karlock prefers aggressive early irrigation of the wound in the office setting or even the emergency department. He says plantar puncture wounds traditionally require high-pressure irrigation and debridement of all dirt and material on the plantar aspect of the foot.

For deep puncture wounds in patients with diabetes, David Swain, DPM, CWS, tends to be more aggressive, noting he has seen these wounds deteriorate with minimal treatment. If the nail went deeply into the foot or potentially touched a bone, he will verify the tetanus status, get proper imaging, verify arterial status and typically do a deep debridement and flush out. With standard wound care, Dr. Swain says the wounds go on to heal if there are no complications.

For younger patients without diabetes, Dr. Swain has seen puncture wounds trigger reflex sympathetic dystrophy/complex regional pain syndrome (RSD/CRPS) so he makes appropriate referrals immediately if the pain is out of proportion or if there are other obvious signs of RSD/CRPS.

Dr. Karlock obtains radiographs and if there is any question of whether an abscess has occurred, he says magnetic resonance imaging (MRI) is warranted. He also notes being somewhat quick to order MRI if early irrigation, debridement and packing of the wound do not lead to a quick resolution of symptoms. If there is any increasing cellulitis or pain, Dr. Karlock says MRI is certainly appropriate.

Even though medical textbooks classically associate puncture wounds with Pseudomonas infection, Dr. Suzuki has seen mostly Staph aureus infection (either methicillin resistant or methicillin susceptible) when he observes wound infection after puncture wounds. If you suspect a penetrating wound down to bone or joints, he advises being diligent about imaging and antimicrobial therapy as a deeper penetrating wound may lead to septic arthritis or osteomyelitis, requiring surgical intervention.

When treating wounds caused by broken glass or glass shards, Dr. Suzuki may take the same approach as he would for puncture wounds caused by nails. He recommends wearing double gloves when treating foot wounds from broken glass as it is very easy to cut yourself inadvertently while trying to retrieve and extract glass shards from the patient’s feet. Dr. Suzuki also recommends using a curette or scalpel, and then debriding the wounds as you pay close attention to the “feel” of the glass pieces. He notes it is often difficult to see clear glass pieces with the naked eye.

Q:

How do you take care of skin lacerations and skin tears in lower extremity?

A:

Dr. Karlock immediately closes simple, non-infected lacerations and usually does not use oral antibiotics unless there is a high rate of contamination. He stresses if the laceration is deep, he may have to explore it in the operating room setting for any deep tendon tears or neurovascular compromise. Dr. Karlock advises diligent treatment of a laceration that has multiple skin tears or avulsions because many of those wound edges will become necrotic and infected. Dr. Karlock says meticulous tissue handling is necessary to avoid compromise of these sometimes fragile wound edges. He traditionally leaves laceration sutures in for 10-14 days, even on the plantar aspect of the foot.

Dr. Suzuki sees “quite a few” skin tears and lacerations in his area as many of his patients have frail skin, are on corticosteroids, or are coming from rheumatology clinics and cancer centers. For skin tears, he has seen many patients and some clinicians try to “save” the bruised skin flap by putting them back on the wound.

“I think I have seen more incidents of infections by approaching skin tears this way, by trapping the contaminants (dirt, bacteria and old blood) under the skin,” notes Dr. Suzuki.

Dr. Suzuki points out the benefits of excising and debriding these bruised skin flaps, which are often nonviable or otherwise grossly contaminated, and then treating the wound with local wound care.  
For elderly patients with large superficial skin tears, Dr. Swain notes sutures placed by ER physicians do not usually work well and almost always dehisce. He prefers to realign the skin (if it is viable) and hold it in place using small Steri-Strips with adequate spacing for drainage. Dr. Swain will subsequently add a nonstick bandage cover, usually with an antimicrobial cream (if there are any signs of infection). Dr. Swain notes the resultant wound after one or two weeks of treatment is usually much smaller and easier to treat. At that point, he will treat the wound with a collagen product every two to three days until complete closure.

When it comes to deeper, large skin lacerations in younger patients, Dr. Swain has found these wounds do well with an adequate saline flush followed by reapproximation with nylon sutures. If there is concern for infection, he says one can debride the area in the OR, flush it with pulsed lavage, loosely approximate closure with sutures and treat it with negative pressure wound therapy (NPWT). Once the wound is superficial, Dr. Swain says one can shift the treatment to using a collagen product every two to three days until complete closure.

For a deeper or larger laceration, Dr. Suzuki says one would want to explore the wound and see if the laceration extends to the joint, tendon or bone. He notes the famous “golden period of laceration repair,” indicating that one should suture a laceration within eight hours or the chance of infection increases exponentially because of bacterial growth.¹ However, Dr. Suzuki says one study recently debunked this “rule” and we now know one may repair a simple and clean laceration up to 24 hours after the injury occurs.² He adds that the existing evidence does not support the oft-cited “golden period.”² He will occasionally perform primary repair of skin tears and lacerations, but has found that lacerations in the foot and ankle are almost never “clean” or simple in comparison to a “kitchen accident,” in which somebody may cut a finger with a clean and sharp knife.

Q:

What is your approach to lower extremity burn wounds, particularly superficial wounds and deep wounds?

A:

For superficial burns, Dr. Swain usually sticks with basic wound care and will treat wounds with Silvadene and Xeroform once daily. “The two work well together and help minimize any pain for the patient,” he notes.

In Dr. Karlock’s practice, he usually treats superficial burns with mupirocin (Bactroban) rather than traditional Silvadene, noting that traditional Silvadene is “somewhat messy to deal with” in his practice. He notes mupirocin has worked well and does not seem to macerate burns. For a superficial wound that is clean, Dr. Karlock does not usually employ any empirical antibiotics. If the wounds become infected and there is more than simple serous drainage, he will then employ oral antibiotics.

For burn wounds, Dr. Suzuki interviews the patient thoroughly to find out the source of heat (hot water, hot oil or hot metal, etc.) and the duration of the heat contact.

“It’s also useful to find out what the patient did after the burn injury as he or she may have correctly washed the burn wound with cool running water, or may have exacerbated the injury by applying ice directly, or applying home remedy topicals (oil, butter, etc.),” he advises.  

As for the treatment of superficial burn wounds, Dr. Suzuki does deroof and decompress any blisters. He treats the resultant open wound with a moist wound dressing just as he would with any other open wound from another etiology. Even though some clinicians may insist on “leaving the blisters alone,” Dr. Suzuki believes the current thinking is to deroof and decompress blisters, noting that the fluid within the blisters is inflammatory and may impede the healing process.

If the burn wound is deep and through the dermis, Dr. Suzuki may allow the wound to demarcate for a few weeks. Then he will surgically excise the resultant pseudo eschar and cover the wound with a split-thickness skin graft or skin substitute, or let it heal with local wound care.

“Although I have seen many burn patients placed immediately on oral antibiotics by urgent care centers, I should note that there is no medical evidence to promote their practice to give prophylactic antibiotics for minor burn wounds,” says Dr. Suzuki.

For deep burns, Dr. Swain’s treatment will depend on the type of structures that are burned or exposed. If the burn is large and involves exposed tendon or bone, then he will take the patient to the OR for debridement, apply an artificial split thickness skin graft (STSG) and possible NPWT.

In regard to deep wounds, Dr. Karlock says once good granulation tissue has occurred, he is not opposed to applying a STSG to expedite closure and avoid amputation.

Dr. Karlock is a Fellow of the American College of Foot and Ankle Surgeons, and is in private practice 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.

Dr. Suzuki is the Medical Director of the Tower Wound Care Center at the Cedars-Sinai Medical Towers. He is also on the medical staff of the Cedars-Sinai Medical Center in Los Angeles and is a Visiting Professor at the Tokyo Medical and Dental University in Tokyo. Dr. Suzuki can be reached via e-mail at Kazu.Suzuki@CSHS.org .

Dr. Swain is a board-certified wound specialist physician (CWSP) of the American Board of Wound Management and a Diplomate of the American Board of Podiatric Medicine. He is a consultant with MiMedx and is in private practice in Jacksonville, Fla.

References

1. Lammers RL, Hudson DL, Seaman ME. Prediction of traumatic wound infection with a neural network-derived decision model. Am J Emer Med. 2003; 21(1):1-7.   
2. Zehtabchi S, Tan A, Yadav K, et al. The impact of wound age on the infection rate of simple lacerations repaired in the emergency department. Injury. 2012; 43(11):1793-8.

Editor’s note: For related articles, see “Key Insights On Treating Burn Wounds In The Lower Extremity” in the July 2006 issue of Podiatry Today or “Expert Insights On Managing Traumatic Wounds” in the November 2007 issue.