The repair of foot lacerations, and especially plantar surface lacerations, has been poorly studied. 5 Few clinical practices regarding foot lacerations have been scientifically evaluated. Due to the inherent risk of infection with foot lacerations, excellent wound irrigation with copious amounts of saline irrigation is essential. The ideal time to perform a thorough dry-field exploration to determine tendon integrity and to detect foreign bodies is when the wound is completely anesthetized.
Debridement removes devitalized tissue, reducing the risk of wound complication. Nonetheless, debridement should be limited on the plantar surface because the thick, dense, fibrous tissue is not pliable. On the sole, any defect resulting from debridement is, therefore, closed under tension across the laceration.
Lacerations associated with nail injuries require close attention. On the dorsum of the phalanx, the skin is attached directly to the periosteum with no intervening layer of subcutaneous tissue. Therefore, a laceration to the nailbed places the underlying bone at risk for bacterial contamination.
The timing of closure must be considered. The foot is a body area with a high concentration of bacteria. Therefore, the risk of foot infection increases significantly 4 to 6 h after the injury.6 A delayed presentation should prompt consideration of a delayed primary closure. Most foot wounds should not be closed after 6 h. If heavily contaminated, the laceration should not be repaired using a primary closure technique, especially if it presents to the ED beyond 3 h from the time of injury. For delayed primary closure, the wound is packed with saline-soaked gauze and the patient is placed on an antistaphylococcal antibiotic. At 96 h after injury, the wound is closed by using interrupted nonabsorbable monofilament sutures.
PLANTAR LACERATIONS When repairing a laceration on the plantar surface, the patient is placed in a prone position. The foot should overhang the cart or be elevated by placing a pillow beneath the ankle. Heavy, large suture needles are required to penetrate the hypertrophied epidermis and dermis of the sole of the foot. Heavy nonabsorbable monofilament suture is used; absorbable suture material is typically avoided in the foot. The plantar surface is approximated without tension usually using 3-0 and sometimes 4-0 suture with a large curved cutting needle. On the plantar surface, simple interrupted sutures usually suffice. The advantage of interrupted sutures is that if the foot becomes infected, individual sutures can be selectively removed. If there is tissue loss or a site is under tension, a vertical mattress suture may be required. In the arch area, achieving tissue eversion can be difficult. Tapes and adhesives are avoided on the plantar surface. Likewise, staples provide an irregular surface for weight bearing.
DORSAL LACERATIONS Dorsal surface lacerations are repaired almost exclusively with nonabsorbable monofilament suture material. Most commonly, 4-0 is used; for small simple lacerations, 5-0 suture can be used. Though running sutures are avoided on the sole, they are acceptable on the dorsal surface. Under select circumstances, tapes and staples can be used.
INTERDIGITAL LACERATIONS Lacerations between the toes are difficult to repair. The interdigital space is confined with a deep-set web space. Having an assistant gently separate the toes enhances the exploration and repair of interdigital lacerations. The use of simple interrupted sutures often leads to skin inversion and risk of failure of the initial wound repair. The most effective closure technique, albeit somewhat more difficult, is to place horizontal or vertical mattress sutures. This is best accomplished with 5-0 monofilament nonabsorbable suture on a small cutting needle. In young children, monofilament absorbable suture can be used, thus avoiding suture removal. When a web space laceration involves the neurovascular bundle, the skin is usually closed without any subsequent consideration to repairing the neurovascular injury.
TENDON LACERATIONS Similar to hand lacerations, flexor tendons are more aggressively repaired than are extensor tendons. Extensor tendon lacerations are sometimes treated with skin closure and splinting. Moreover, extensor tendon lacerations involving the midfoot and forefoot can often go unrepaired without sacrificing any necessary foot function. Regarding tendon lacerations across the toes (excluding the great toe), both extensor and flexor tendon injuries can be ignored without significant functional sequelae. Occasionally, a hammer toe or claw toe deformity results from the failure to repair a tendon (usually flexor tendon) laceration. 7 Although 80 to 93 percent of surgeons recommend repair of the flexor hallucis longus, no long-term evaluation has determined that this is essential. 5 In fact, there is limited information that unrepaired flexor hallucis longus tendon lacerations do not result in a functional deficit, even among athletes. 8 Nonetheless, adhesion formation is a common complaint. Lacerations to the flexor tendons of the other toes are usually unrepaired.
RETAINED FOREIGN BODIES Retained (nonreactive) foreign bodies such as glass can pose a problem. Chronic pain, especially during walking, can occur if the material is not removed. In the absence of chronic discomfort, inert foreign bodies can remain in the foot. The material typically becomes encapsulated, as is sometimes seen with insulin needles retained in the foot of patients with diabetic neuropathy. Obviously, organic material must be aggressively sought. Deep foreign bodies in the foot can be extremely difficult to remove in the ED. Surgical consultation and removal under fluoroscopy can be required.
HAIR STRANGULATION Hair strangulation-amputation is an unusual type of toe injury that is seen during infancy. A long strand of hair becomes wrapped around a toe and can involve several loops of the hair strand, all of which must be removed. This can be an occult source of irritability for infants. Removal must be complete so that the neurovascular bundle is not transected. Moreover, complete removal eliminates any further circumferential laceration of the skin around the toe. A novel approach to removal involves the use of hair-dissolving compounds. This approach has not been studied sufficiently to recommend it. The most certain approach to salvage the compromised digit is to make a midline longitudinal incision along the extensor surface of the toe. The incision should be deep enough to split the fibers of the extensor ligament without transecting the fibers. The multiple strands of hair are then removed using fine forceps without teeth. Unfortunately, the toe often retains the initial appearance, making one uncertain whether all of the strands have been removed or cut.
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