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
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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
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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
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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