Lacerations of the leg and foot
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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

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LACERATIONS OF THE LEG AND FOOT

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Lacerations of the leg and foot

LACERATIONS OF THE LEG AND FOOT

BY

S. SUPALERK


Introduction

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

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


Lacerations of the leg and foot

  • 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

Physical examination

  • Location

  • Length

  • Depth

  • Shape of wound

  • Weight bearing surface

  • Distal sensory nerve function

  • Motor function

  • Vascular integrity


Lacerations of the leg and foot

  • 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

Ancillary studies


Treatment

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

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 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


Lacerations of the leg and foot

  • 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

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

Dorsal laceration

  • Nonabsorbable monofilament suture material

  • Running sutures are acceptable

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


Inter digital laceration

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

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

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

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


Lacerations of the leg and foot

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

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

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

Hair tourniquet Syndrome

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


Disposition

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

Prophylactic Antibiotic Use

  • Clinical adjustment according

    • Degree of contamination

    • Presence of foreign body

    • Presence of associated injury

    • Host factors


Amoxicillin clavulanate

Amoxicillin - Clavulanate

  • Animal bite : staphylococcus , streptococcus , pasteurella

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

  • Open fractures

  • S.aureus

    • First – generation cephalosporin

    • aminoglycoside


Lacerations of the leg and foot

fluoroquinolone

Compartment syndrome , myonecrosis , foot amputation

  • Freshwater stream

    • Aeromonas hydrophila

    • Gramnegative bacillus

Aminoglycosides

Trimethoprim – sulfamethoxazole

fluoroquinolones


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