The Journal of Foot & Surgery 55 (2016) 161–165

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The Journal of Foot & Ankle Surgery

journal homepage: www.jfas.org

Dermal Fenestration With Negative Pressure Therapy: A Technique for Managing Soft Tissue Associated With High-Energy Complex Foot Fractures

Henrietta Poon, MRCS 1, Heather Le Cocq, FRCS 2, Alistair J. Mountain, FRCS 1, Ian D. Sargeant, FRCS 1

1 Royal Centre for Defence Medicine, Birmingham, United Kingdom 2 Leeds Teaching Hospital National Health Services Trust, Birmingham, United Kingdom article info abstract

Keywords: Military casualties can sustain complex foot fractures from blast incidents. This frequently involves the calcaneum and is commonly associated with mid-foot fracture dislocations. The foot is at risk of both calcaneum compartment syndrome and the development of fracture after such injuries. The amount of energy compartment syndrome transfer and the environment in which the was sustained also predispose patients to potential skin dermis necrosis and deep infection. Decompression of the compartments is a part of accepted practice in civilian fasciotomy trauma to reduce the risk of complications associated with significant soft tissue swelling. The traditional pilon fracture methods of foot fasciotomy, however, are not without significant complications. We report a simple technique of dermal fenestration combined with the use of negative pressure wound therapy, which aims to preserve the skin integrity of the foot without resorting to formal fasciotomy. Ó 2016 by the American College of Foot and Ankle Surgeons. All rights reserved.

Improvised explosive devices (IEDs) are the signature weapon postoperatively (8,9). Varela et al (10) reported an incidence of 10.9% used by the insurgents against coalition troops in the recent conflicts fracture blister formation in all calcaneal fractures. Our experience in Iraq and Afghanistan (1). IEDs encompass a wide variety of devices with managing military casualties with closed hindfoot and mid-foot from crudely made devices, using home-made explosives, to complex fractures has always been complicated by the presence of extensive explosive systems involving military grade explosives capable of soft tissue blistering and swelling. The timing of calcaneal fracture causing multiple fatalities and severe injury. surgery is contentious. It has been suggested that surgery should be Studies from the UK and US Joint Trauma Registries have shown delayed 72 hours to avoid wound complications (11). However, that most combat are located in the extremities (2–5).In others have advocated very early operative intervention to avoid the some instances, when the lower limb has not been immediately edematous phase that begins at around 6 hours after injury (10,12). traumatically amputated by the blast itself, explosions can result in However, UK military casualties injured while on duty undergo initial severe injuries to the calcaneum by acceleration of the vehicle floor, resuscitation and fracture stabilization in a field hospital (role 3), with the forces transmitted to the foot (6). where internal fixation is not within current UK military practice. Open calcaneal fractures after blast injury are associated with a Transfer to a UK hospital (role 4) for definitive treatment by aero- poor prognosis and often lead to a high rate of amputation (7). medical evacuation, precluding the option of early definitive surgery However, even in closed injuries, significant soft tissue injury can and the possibility of avoiding swollen soft tissue and its inherent occur. Fracture blisters and soft tissue swelling are common compli- potential complications. cations of any acute calcaneal fractures, preoperatively or The major concern regarding fracture blisters is their progression to full dermal necrosis, which subsequently requires complex plastic surgical reconstruction. The cosmetic appearance of free tissue transfer Financial Disclosure: None reported. to the foot is seldom welcomed by the patient and inevitably reduces Conflicts of Interest: None reported. their ability to wear normal footwear (13). In addition, complex plastic Address correspondence to: Henrietta Poon, MRCS, Royal Centre for Defence reconstruction results in an insensate tissue transfer, which is not Medicine, Leeds Teaching Hospital National Health Services Trust, Birmingham B15 2WB, United Kingdom. ideal in a weightbearing structure (14). Many of the calcaneal fractures E-mail address: [email protected] (H. Poon). have poor functional outcome, leading to elective amputation. Our

1067-2516/$ - see front matter Ó 2016 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2015.08.014 162 H. Poon et al. / The Journal of Foot & Ankle Surgery 55 (2016) 161–165 strategy has been to avoid free tissue transfer, which has a high risk Afghanistan to a UK hospital to undergo fracture fixation surgery 3 of being discarded with the limb at a later amputation (15). days after their initial injury. Strategies have been used to prevent and treat fracture blisters, During the first trip to the operating theater in the United although most investigators have agreed that compression and Kingdom, fracture fixation was performed with dermal fenestration in elevation are key in the initial stage, further treatments of fracture both patients. Dermal fenestration involves multiple stab incisions of blisters include aspiration, de-roofing, application of sliver sulfadia- 0.2 cm (Fig. 3) at the site of the fracture blisters and swollen areas zine, and even leaving the blister intact and simply covering it with (Figs. 4 and 5) of potential blister formation using a no. 15 scalpel loose dressings (16,17). blade. The scalpel was used in the line of the cutaneous nerves to Significant soft tissue swelling can result in compartment syn- reduce the risk of damage to these structures. The depth of the inci- drome of the foot. Although usually a rare complication of foot in- sion should be no more than the thickness of the skin to reduce the juries, it has been described after crush and blast injuries, in risk of vascular injury. Within 30 minutes of performing fenestration, particular, if the Lisfranc joint, Chopard joint, or the calcaneum is it will be clearly seen that the overall size of the foot has been reduced, involved (18–20). Ritenour et al (21) reported that combat casualties with many points of punctate hemoserous oozing. We performed this have an increased risk of developing acute compartment syndrome technique concurrent with definitive fracture management in the owing to the high-energy mechanism of injury. Their data showed a presented patients and at separate trips to the theater before fracture higher fasciotomy rate in military casualties compared with civilian fixation in other patients. trauma data (21). Treatment by decompression is debatable, and current expert opinion within the UK Defence Medical Service has advocated a high index of suspicion and intervention (22). Negative pressure wound therapy (NPWT) has been used widely in the management of trauma wounds in recent years. In particular, it has been used in large, complex, and exudative wounds sustained by coalition forces from IEDs in the recent conflicts in Iraq and Afghanistan (23,24). We describe an innovative technique that combines decompres- sion of soft tissue swelling and application of NPWT as a part of the strategy to prevent soft tissue swelling and fracture blisters in closed complex foot fractures from progressing to full dermal necrosis or compartment syndrome.

Surgical Technique

We describe our technique using photographs from 2 of our pa- tients. Patient 1 was a 41-year-old male soldier who had sustained right closed calcaneum and pilon fractures (Fig. 1) in an IED explosion during a foot patrol. Patient 2 was a 25-year-old male soldier with left complex ankle and mid-foot fractures sustained from an IED explo- sion (Fig. 2). Both patients were aeromedically evacuated from

Fig. 1. Computed tomography reconstruction of right comminuted calcaneum fracture in patient 1. Fig. 2. Radiograph of left complex ankle and mid-foot fractures in patient 2. H. Poon et al. / The Journal of Foot & Ankle Surgery 55 (2016) 161–165 163

Fig. 5. Extensive tissue swelling in patient 2.

closed wound environment. The pressure of the V1STA (Smith & Nephew, London, UK) is set at 80 mm Hg. The absence of leaks is ensured by checking the maintenance of the pressure on the machine. On removal of NPWT in our patients, the soft tissue appeared healthy, with minimal scarring from the dermal fenestration (Figs. 6 to 8).

Discussion

Severe axial loading is exerted on the lower extremities either by explosions occurring from beneath or when the casualty is thrown off the ground and lands on their feet. Ramasamy et al (25) demonstrated in their study that the environment (i.e., mounted and dismounted) in which the explosion occurs has an effect on the Fig. 3. Dermal fenestration from multiple stab incisions in patient 2. type of blast injury seen. Also, although the structure of a vehicle can mitigate the peak overpressure (primary) and moving object (sec- ondary) related injuries, the tertiary blast effect and lower extremity Before application of the NPWT, the wound and surrounding fractures are more common in an enclosed environment such as a skin are meticulously cleaned to allow formation of a closed seal vehicle owing to movement and displacement of the vehicle’s under vacuum. The use of tincture of benzoin at the skin adjacent occupants. to the wound can enhance adhesiveness to prevent leakage at More than 70% of explosive combat injuries are located on the junctional areas. KerlixÔ gauze (Covidien, Farmington, CT) is then extremities (1), causing a mixture of traumatic injuries at the laid onto the wound bed, covering all the areas of skin and blister scene. These include complete traumatic amputation, nonviable but that underwent dermal fenestration. A drain is then placed onto attached limbs, and attached and viable but extremely complex bony the gauze, followed by a film to complete the seal and produce a and soft tissue injuries. Calcaneal fractures are not uncommon and are

Fig. 4. Blister at right medial malleolus of patient 1. Fig. 6. Patient 1 with healing of previous blister site at day 22 (from the date of injury). 164 H. Poon et al. / The Journal of Foot & Ankle Surgery 55 (2016) 161–165

Fig. 7. Patient 2 with healing of previous extensive tissue swelling site at day 25 (from the date of injury). often associated with multiple other injuries in the military setting. Ramasamy et al (25) noted a rate of associated spinal injuries in the combat zone similar to the rate of 21% noted in falls from a height >2 stories of a building in the civilian setting. As discussed, infection is a serious complication of calcaneal fractures. In military open fractures, a higher rate of infection can be anticipated owing to contamination of the wounds resulting from the austere environment, propulsion of fragments and dirt deep into the tissue planes, and severe commi- nution of fractures owing to the significant forces present in explosive injuries. IEDs causing calcaneal fractures can occur when dismounted (soldier on foot patrol) or mounted (in a vehicle). Ramasamy et al (6) described the modern “deck-slap” injury of calcaneal blast fractures from vehicle explosions, in which, on detonation of the device, the vehicle floor slams into the sole of the foot. If the calcaneal injury is at that point not an open one, a high chance still exists of it becoming so by the external explosive forces causing crushing of the soft tissue, the severity of the fracture itself, the dirt of the Afghanistan environment, Fig. 8. Patient 2 with minimal scarring from the dermal fenestration site at 9 months after limited hygiene, and poor nutritional status of the combat soldier who treatment. lacks his normal diet and has been expending more calories than he takes in. IED-related calcaneal fractures, therefore, have a high infection and amputation rate and only a few casualties are able re- risk of developing blisters is beneficial. Rapid surgical decompression turn to preinjury military duties (6). during open reduction can release the soft tissue and drain the sub- Most fracture blisters are thought to form within 24 hours (10). cutaneous . Fixation of bleeding fracture surfaces can result Initial swelling mainly results from the hemorrhage from torn blood in swelling reduction and provide an improved environment for soft vessels, leading to hemarthrosis or hematoma. After 6 hours, inter- tissue viability. Definitive surgery for complex orthopedic injury is not stitial edema appears due to the increased vasodilation and yet appropriate in a deployed field hospital. Surgery undertaken at a role decreased perfusion to traumatized tissue. This edema separates the 3(field) hospital should be performed with regard to later recon- epidermis from the dermis; fluid then fills the deficit to form the structive options and function preservation (26). Hence, rapid surgical fracture blister. A case also exists for fracture blisters being more decompression should not occur unless foot viability is absolutely at common in the area of the ankle (than at other anatomic locations) threat. because of the unique differences found in ankle skin. Zirm (12) Foot fasciotomy is not without complications. The main indication described flattened epidermal papillae over the malleoli, signifying for foot fasciotomy is impending or obvious compartment syndrome a lack of arterioles between the rete ridges. Furthermore, the amount characterized by severe unremitting pain. The aim is to reduce the of subcutaneous fat is sparse and well-formed adipose or muscular morbidity of the contractures associated with muscle necrosis from layers are lacking. The skin is relatively thin, a collection of veins is the microvascular compromise resulting from the increased pressure present medially, and fewer hair follicles are present in this area. Hair in closed compartments (27). However, one of the main concerns with follicles are thought to aid re-epithelialization in healing of split-skin the fasciotomy procedure is wound closure. Myerson (18) reported on graft donor sites and might help anchor the dermis to the epi- a series of 14 patients. Of these patients, 11 required split-skin grafting dermisdso their relative lack in this area might be a factor in blister and 3 achieved delayed primary closure (18). Other complications formation. Although the calcaneum lies below true ankle skin, it is in included bleeding, nerve injury, and wound infection. Established foot close proximity and shares some of the features of ankle skin compartment syndrome without decompression will lead to con- described. tractures and toe deformities; however, controversy exists regarding Advocates for early intervention for calcaneal fractures believe that the significance of these complications compared with the morbidity surgery within 6 to 8 hours of injury for patients with fractures at high associated with foot fasciotomy (28). H. Poon et al. / The Journal of Foot & Ankle Surgery 55 (2016) 161–165 165

NPWT works by applying subatmospheric pressure to a wound 5. Owens BD, Kragh JF Jr, Macaitis J, Svoboda SJ, Wenke JC. Characterization of ex- filter material placed onto the wound bed (i.e., to the fenestrated and tremity wounds in Operation Iraqi Freedom and Operation Enduring Freedom. J Orthop Trauma 21:254–257, 2007. blistered areas over the calcaneum) and covered by an airtight seal to 6. Ramasamy A, Hill AM, Phillip R, Gibb I, Bull AM, Clasper JC. The modern “deck- draw exudate to the canister collection device. It acts as a closed slap” injurydcalcaneal blast fractures from vehicle explosions. J Trauma 71:1694– sealed wound device that maintains aseptic conditions as far as is 1698, 2011. 7. Ramasamy A, Hill AM, Masouros S, Gibb I, Phillip R, Bull AM, Clasper JC. Outcomes possible and avoids soiled dressings. This is perhaps particularly of IED foot and ankle blast injuries. 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