Treating Traumatic Wounds
Offering expert opinions on treating skin lacerations and tears, burn wounds and puncture wounds, four DPMs also provide insights on when and when not to use prophylactic antibiotics for these wounds.
Q:
How do you treat lower extremity skin lacerations and skin tears?
A:
The goal of treatment for skin lacerations and tears is to reapproximate the skin edges without devitalizing the vascularity to the soft tissue, note Lawrence Fallat, DPM, FACFAS, and Ashim Wadehra, DPM. With any open injury, they note one should thoroughly irrigate the wound.
Although Kazu Suzuki, DPM, CWS, acknowledges the “golden period” of laceration repair (i.e. one can close the laceration as long as it’s within five hours of injury), he notes that more often than not, he prefers to take care of laceration and skin tears in lower extremities as he would treat any open wounds. He notes a few incidents when he repaired and closed a supposedly “clean” wound that got badly infected.
Nicholas Bevilacqua, DPM, FACFAS, advises ascertaining a thorough history to determine the mechanism and timing of injury. He and Drs. Fallat and Wadehra suggest administering tetanus prophylaxis when indicated (if tetanus status is unknown or more than 10 years since the last dose for clean, minor wounds and more than five years since the last dose for contaminated wounds). Drs. Fallat and Wadehra advise considering prophylactic antibiotic therapy to prevent infection, especially in dirty wounds.
Dr. Bevilacqua performs the initial inspection and exploration of the laceration in the emergency room. If deeper structures are involved (arteries, nerves, tendons, joint capsule and bone), he further explores the wound and manages it in the operating room. Dr. Bevilacqua says one may treat simple, superficial lacerations in the ER and utilize local anesthesia. The wound should have copious irrigation and debridement of any foreign material and devitalized tissue, notes Dr. Bevilacqua.
Dr. Bevilacqua says one should close the laceration with minimal tension using non-absorbable sutures. If adequate soft tissue covering is available, provided the wound is clean, Drs. Fallat and Wadehra will place simple interrupted sutures with 2-0 or 3-0 nylon to close the wound. They will use retention sutures on larger wounds in which closure is difficult or if the wound is considerably dirty.
If there is a delay in presentation, Dr. Bevilacqua says one should irrigate the wound, debride it and leave it open to heal by secondary intention. He closely follows patients on an outpatient basis and monitors them for the development of any local signs and symptoms of infection.
Q:
How do you approach lower extremity puncture wounds, such as wounds resulting from stepping on nails and broken glass?
A:
Dr. Bevilacqua advises performing a thorough history to determine the causative object of the puncture wound, timing of injury and the shoe gear worn at the time of injury. Evaluation of the wound is important to determine wound size, the depth of penetration and to identify retained foreign body, debris and devitalized tissue, says Dr. Bevilacqua.
For patients with puncture wounds, Drs. Fallat and Wadehra begin with a full tetanus workup, administering tetanus toxoid and/or tetanus immunoglobulin depending on the patient’s vaccination history and presentation of the wound.1 Dr. Bevilacqua also advises administering tetanus prophylaxis when indicated.
Drs. Fallat and Wadehra take serial radiographs to watch for osteomyelitis, a potential complication of a puncture wound, and also to watch for gas in the tissue. Dr. Bevilacqua also takes radiographs to evaluate for retained foreign body and inspect surrounding osseous structures. However, he cautions that some objects are difficult to visualize on radiographs. Dr. Suzuki may take a foot X-ray if there is a suspected bone injury but he has also found over the years that X-rays are not that helpful in identifying a small piece of glass or a foreign body, unless it is a metal piece like a shotgun pellet.
“Although you may see in a medical textbook about a correlation between puncture wounds and Pseudomonas infection, I personally never saw that correlation and I would treat puncture wounds as any other open wound by taking a good wound culture and treating it selectively,” asserts Dr. Suzuki.
All four panelists note that puncture wounds receive copious irrigation with Dr. Suzuki noting that he “irrigates the heck” out of the wound to remove any foreign body that may be left in the foot. Drs. Fallat and Wadehra take wound cultures and administer broad spectrum antibiotics. They add that those who have suffered a puncture wound through their shoe gear receive antibiotics for Pseudomonas coverage.
Dr. Suzuki usually excises the puncture wound under local anesthetic injection. Dr. Bevilacqua says one may treat superficial, cutaneous puncture wounds in the office or ER, and utilize local anesthesia while one can best manage deeper penetrating puncture wounds in the OR. He notes that the penetrating object may inoculate bacteria and foreign debris into the wound, and emphasizes that aggressive debridement of foreign debris and devitalized tissue is paramount to reduce the risk of infection. Dr. Bevilacqua packs the wound open and and closely monitors it for any development of local signs of infection.
If there is a retained foreign body in the acute setting, Drs. Fallat and Wadehra attempt bedside removal of the foreign body. If this is not successful, they will take the patient to the OR for an incision and drainage with removal of the foreign body.
“One must take caution not to inadvertently push the foreign body further into the soft tissue,” note Drs. Fallat and Wadehra. “It is important to follow the course of the puncture wound when attempting removal of a retained foreign body to prevent deepening.”
Q:
What is your treatment for lower extremity burn wounds? How do you handle superficial burn wounds? What about deep burn wounds?
A:
As burns are debilitating injuries, Drs. Fallat and Wadehra advise taking proper care to prevent infection. They begin with a physical examination in order to determine the severity of the burn as well as the patient’s neurovascular status. For superficial burns, they begin local wound care. Drs. Fallat and Wadehra recommend applying 1% sulfadiazine cream once daily with regular dressing changes.
For superficial burn wounds and blisters, Dr. Suzuki deroofs the blisters or debrides any non-viable skin and tissues to expose the clean wound base. Then he treats the burn as any other open wound.
“I am aware of the mantra to ‘leave the blister alone as a biological dressing’ but it never made much sense to me. There are a lot of inflammatory fluids inside that blister and the blister is bound to break at any point, which is inconvenient and unhygienic to the patient,” says Dr. Suzuki. “I think I would much rather clean out the blister and apply appropriate non-adherent wound dressings.”
Third- and fourth-degree burn wounds would need excision of burned tissue (pseudo-eschar), and those patients most likely need to be admitted to the hospital, according to Dr. Suzuki. After the excision of burned tissues, he usually applies split thickness skin grafting (STSG) from a calf or sole of the foot, although he has used various skin substitute grafts in the past. Dr. Suzuki says they are a viable alternative as long as the wound is relatively small (5 x 5 cm or smaller), given the cost of a large skin substitute graft.
Although physicians can treat deeper burns with local wound care, Drs. Fallat and Wadehra note that sometimes burns require the debridement of all non-viable tissues. For burn injuries that are large with non-viable skin, they utilize skin grafts and/or rotational flaps.
Nerone and colleagues reviewed 33 diabetic foot burns and noted that 18 required surgical intervention.2 Drs. Fallat and Wadehra say the authors advise prophylactic antibiotics for prevention of infection in cases of diabetic foot burns. Memmel and coworkers found that patients with diabetes presenting with burn wound cellulitis were infected with multiple organisms including methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas.3 Drs. Fallat and Wadehra says the authors advise performing a tetanus workup on these patients as well.
Q:
Do you prescribe prophylactic antibiotics in traumatic wounds and lacerations?
A:
Dr. Suzuki does not believe in providing prophylactic oral antibiotics for minor traumatic wounds, seeing no good medical evidence for it. However, he believes it it is prudent to give IV antibiotics in open fractures in the hospital setting as one is actively trying to prevent osteomyelitis.
“I shake my head every time I see my patients given a 10-day course of PO antibiotics when they visit urgent care centers for a minor open wound on weekends,” says Dr. Suzuki.
Dr. Bevilacqua determines the use of prophylactics on a case by case basis. As he notes, simple lacerations and superficial puncture wounds in a healthy patient generally do not require antibiotics. He will give prophylactic antibiotics to immunocompromised patients as well as patients presenting with dirty, contaminated wounds. Dr. Bevilacqua says one should direct antibiotics against the most common organisms, staphylococci and streptococci.
Dr. Bevilacqua treats all infected wounds with a combination of surgical debridement and antibiotics. He initiates empiric antibiotic therapy and adjusts antibiotics accordingly based on deep tissue culture results.
Dr. Bevilacqua is in private practice at North Jersey Orthopaedic Specialists in Teaneck, NJ. He is board-certified in both Foot Surgery and Reconstructive Rearfoot and Ankle Surgery by the American Board of Foot and Ankle Surgery. Dr. Bevilacqua is a Fellow of the American College of Foot and Ankle Surgeons.
Dr. Fallat is the Director of the Podiatric Surgical Residency at Beaumont Hospital-Wayne in Wayne, Mich. He is a Fellow of the American College of Foot and Ankle Surgeons.
Dr. Suzuki is the Medical Director of the Tower Wound Care Centers 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. He can be reached at Kazu.Suzuki@cshs.org.
Dr. Wadehra is a first-year surgical resident in the Department of Podiatric Surgery at Beaumont Hospital-Wayne in Wayne, Mich.
References
- Resnick CD, Fallat LM. Puncture wounds: therapeutic considerations and a new classification. J Foot Ankle Surg. 1990; 29(2):147-153.
- Nerone VS, Springer KD, Atway SA. Diabetic foot burns: a case series. J Foot Ankle Surg. 2014; 53(4):453-455.
- Memmel H, Kowal-Vern A, Latenser BA. Infections in diabetic burn patients. Diabetes Care. 2004; 27(1):229-233.
For further reading, see “How To Treat Puncture Wounds” in the October 2014 issue of Podiatry Today or “Key Insights On Treating Burn Wounds In The Lower Extremity” in the July 2006 issue.
