LACERATIONS OF THE LEG AND FOOT

BY

S. SUPALERK

Introduction

• Any injury to the lower extremity (especially the foot ) jeopardizes the ability to walk

• From simple plantar puncture wounds to catastrophic lawn mower injuries

• Soil contamination , risk of infection , worsening scarring , slowing healing

Clinical features

• History– Time interval : increase incidence of infection– Mechanism of injury : underling tissue – Risk of retained foreign body– Degree of potential contamination– Complaint any new paresthesia , anesthesia

weakness or loss of function suggests a nerve vascular or tendon injury prompting a careful examination

• Past medical history– Tetanus immunization status – Condition increase risk for infection or

delayed wound healing ( DM , immunosuppression ) and risk of bacteremia ( valvular heart disease , asplenia )

– Other medication

Physical examination

• Location• Length• Depth• Shape of wound• Weight bearing surface• Distal sensory nerve function• Motor function• Vascular integrity

• Nerve : light touch , static two-point discrimination– Superficial peroneal N. : foot eversion– Deep peroneal N. : foot inversion , ankle dorsiflexion– Posterior tibial N. : ankle plantar flexion

• Tendon : direct visual because partially lacerated tendon can mimic normal fuction

• Foreign bodies

Ancillary studies

• CBC• ESR• CRP• H/C

• Radiographic imaging– Foreign body– Fracture– Joint space

• CT• MRI

Treatment

Age considerations• Elderly

– thin skin , decrease subcutaneous fat– Medical condition : delay wound healing– Tetanus immunization

• Child– Difficulty limit movement – Contaminated wound– The smaller the child, the larger the dressing

Wound anesthesia

• Sensory examination precede anesthesia

• Dorsum foot , local anesthesia

• Plantar surface , nerve blocks (sural , posterior tibial )

• Toes , digital nerve blocks

• Topical anesthetic poorly effective on dense epidermis

Wound preparation and repair

• Wound irrigation • anesthesia• Dry field exploration : tendon , FB• LW multiple layered closure decrease

tension and simple interrupted , horizontal mattress suture use moderate tension , large LW avoid running sutures , infection

• Debridement to remove devitalized tissue decrease risk of wound complication

• Timing of closure , delay in closure

• Delay primary closure less than 6 hr in case delayed presentation or contamination : pack saline soaked gauze

• Antibiotic

• reevaluated case

Plantar laceration

• Pron position• Heavy , large suture needles and thick

thread penetrate the hypertrophied epidermis and dermis of foot and sole , large curved cutting needle

• Simple interrupted sutures• Tissue loss or under tension use vertical

mattress suture • Avoid adhesive tapes , tissue adhesives ,

staples

Dorsal laceration

• Nonabsorbable monofilament suture material

• Running sutures are acceptable

• Under select circumstances adhesive tapes with splints 5-7 days

Inter digital laceration

• Between toe very difficult to repair

• Simple interrupted suture

• When the web involve neurovascular , the skin usually closed without any subsequent consideration to repair neurovascular

Skin laceration

• Wound over the anterior tibial surface are under considerable tension suggest multiple layered closure

• Elderly extremely thin and difficulty for closure suggest multiple layered

• Elastic bandage is placed over a generous dressing

• Weight bearing limited for 5 days • Alternative : deep reinforced sutures placed

through adhesive strips laid down parallel to the wound edges has been recently described

Knee laceration

• Joint capsule penetration , LW of patellar and quadriceps tendons should be assessed

• Common peroneal nerve is prone to injury check inversion , eversion , dorsiflexion

• Deep popliteal wound : popliteal artery ( minimal collateral circulation distal to knee ) , tibial nerve

• Mark active skin tension : knee immobilized

Tendon laceration

• Repair tendon laceration in foot depend on functional impairment

• Tendon at Mid foot and forefoot can go unrepaired ( without sacrificing any necessary foot function ) can close skin and splint

• Extensor hallucis longus or tibialis anterior : call orthopedist because dorsiflexion of the great toe and foot important in walking and running

• Achilles tendon is first palpated for defects : Thomson test

• Repair a few days to weeks after initial injury

• Skin closure , splinting of the foot

• Antibiotic prophylaxis

• Non-weight bearing

• Follow up orthopredist

Tissue loss and Amputation

• Major tissue loss as well as toe amputation• Tissue grafts and flap reconstruction by an

orthopedist or plastic surgeon• Serve part :

– wash gently with sterile saline – wrapped in saline-soak gauze– placed in plastic bag and closed – placed ice water bath

Retained foreign bodies

• Nonreactive FB ( glass ) is show chronic pain or chronic discomfort during walk if not removed

• Reactive organic material must aggressively sought and removed

• Fluoroscopy can use to help locate and remove radiopaque FB

Hair tourniquet Syndrome

• Strangulation and digital ischemia seen during infancy : long strand of hair wrapped around a toe

Disposition

• Bulky dressing is applied to plantar surface

• Weight-bearing is avoided for at least 5 days

• Elevation : decrease swelling and infection risk

• Typically removed sutures in 10 – 14 days

Prophylactic Antibiotic Use

• Clinical adjustment according– Degree of contamination– Presence of foreign body– Presence of associated injury– Host factors

Amoxicillin - Clavulanate

• Animal bite : staphylococcus , streptococcus , pasteurella

• Asplenic or immunocompromised sustain dog bite : C.canimorsus.

• Open fractures• S.aureus

– First – generation cephalosporin– aminoglycoside

fluoroquinolone

• Freshwater stream – Aeromonas hydrophila– Gramnegative bacillus

Compartment syndrome , myonecrosis , foot amputation

• Aminoglycosides• Trimethoprim –

sulfamethoxazole• fluoroquinolones