medigraphic.com

2025, Number 5

<< Back Next >>

Rev Fac Med UNAM 2025; 68 (5)

Severe Foot Trauma: Management with Negative Pressure Wound Therapy, Acellular Dermal Matrix, and a Multidisciplinary Approach

King-Martínez AC, Pacheco-Díaz C, Cañas-Alcocer D, Torres-Sánchez L, Castillo-Aguilar E, Oropeza-Bonfanti F, Cuéllar-Avaroma A

Language: Spanish
References: 34
Page: 19-29
PDF size: 340.71 Kb.


ABSTRACT

Background: Severe extremity trauma remains a clinical challenge, particularly in pediatric patients. Advanced wound management techniques and a multidisciplinary approach have expanded the possibilities for limb preservation in these cases.
Case report: We describe the case of a 15-year-old male who sustained severe foot trauma after entrapment in a motorcycle chain. The injury involved multiple fractures, tendon and skin loss, with significant contamination. Initial care was delayed for more than 8 hours, increasing the risk of infection. Upon hospital admission, and after antibiotic administration, extensive surgical debridement and negative pressure wound therapy (NPWT) were performed, providing secretion control, granulation, and temporary coverage. The patient required eight surgical debridements during hospitalization, with antibiotic therapy guided by pediatric infectious disease specialists based on tissue cultures. Definitive stabilization was performed with Kirschner wires; an Achilles tenotomy was added to avoid equinus, and the application of an acellular dermal matrix combined with NPWT was used to achieve definitive wound closure.
Results: A multidisciplinary approach (orthopedics, pediatric infectious disease, rehabilitation, and psychology) was fundamental to optimize recovery. Partial weight-bearing was initiated at 2 months, and by 8 months the patient was performing daily and sports activities with minimal limitation. At follow-up, he presented with a functional foot and minimal limp using standard footwear.
Conclusion: This case reflects the importance of individualized surgical decision-making supported by scoring systems such as MESS, repeated adequate surgical debridements, and the role of advanced therapies such as NPWT and dermal substitutes in severe trauma to the lower limb. We show how comprehensive multidisciplinary care can help preserve severely injured extremities and achieve satisfactory functional outcomes in pediatric patients.


REFERENCES

  1. Berrones-Sanz LD. Análisis de los accidentes y las lesiones delos motociclistas en México. Gac Med Mex. 2017;153(6):-.Disponible en: http://dx.doi.org/10.24875/GMM.17002812

  2. Instituto Nacional de Estadística y Geografía (INEGI).Accidentes de tránsito terrestre en zonas urbanas y suburbanas,conjunto de datos: Accidentes terrestres. Disponibleen: https://www.inegi.org.mx/sistemas/olap/consulta/general_ver4/MDXQueryDatos.asp?#Regreso&c=13159

  3. Zuelzer DA, Hayes CB, Hautala GS, Akbar A, MayerRR, Jacobs CA, y colaboradores. Early antibiotic administrationis associated with a reduced infection riskwhen combined with primary wound closure in patientswith open tibia fractures. Clin Orthop Relat Res.2021;479(3):613-9. Disponible en: https://doi.org/10.1097/CORR.0000000000001507

  4. Foote CJ, Tornetta P 3rd, Reito A, Al-Hourani K,Schenker M, Bosse M, y colaboradores. A reevaluationof the risk of infection based on time to debridement inopen fractures: results of the GOLIATH meta-analysis ofobservational studies and limited trial data. J Bone JointSurg Am. 2021;103(3):265-73. Disponible en: https://doi.org/10.2106/JBJS.20.01103

  5. Rupp M, Popp D, Alt V. Prevention of infection in open fractures:where are the pendulums now? Injury. 2020;51(Suppl2):S57-S63. Disponible en: https://doi.org/10.1016/j.injury.2019.10.074

  6. Johansen K, Daines M, Howey T, Helfet D, Hansen ST Jr. Objectivecriteria accurately predict amputation following lowerextremity trauma. J Trauma. 1990;30(5):568-73. Disponibleen: https://doi.org/10.1097/00005373-199005000-00007

  7. Águila-Ledesma IR, Medina-Rodríguez F, Altamirano-Gutiérrez LM, Núñez-Gómez DA, Torres-González R,Pérez-Atanasio JM. Patrón de decisión quirúrgica en laprescripción de amputaciones con escala MESS en fracturasde tibia expuesta grado III-B Gustilo-Anderson. ActaOrtop Mex. 2019;33(1):2-7.

  8. Franco-Cendejas R. Vigilancia epidemiológica de la infeccióndel sitio quirúrgico en ortopedia. Ortho-tips. 2020;16(1):7-15. Disponible en: https://doi.org/10.35366/93511

  9. Akın M, Topaloğlu S, Özel H, Avşar FM, Akın T, Polat E,y colaboradores. Awareness and wound assessment decreasesurgical site infections. Turk J Surg. 2021;37(2):133-41. Disponibleen: https://doi.org/10.47717/turkjsurg.2021.5059

  10. Lee C, Rasmussen TE, Pape HC, Gary JL, Stannard JP,Haller JM. The polytrauma patient: current concepts andevolving care. OTA Int. 2021;4(2 Suppl):e108(1-6). Disponibleen: https://doi.org/10.1097/OI9.0000000000000108

  11. Cao X, Hu Z, Zhang Y, Wang P, Huang S, Zhu W, y colaboradores.Negative-pressure wound therapy improves take rate ofskin graft in irregular, high-mobility areas: a randomized controlledtrial. Plast Reconstr Surg. 2022;150(6):1341-9. Disponibleen: https://doi.org/10.1097/PRS.0000000000009704

  12. Hill DM, Hickerson WL, Carter JE. A risk-benefit reviewof currently used dermal substitutes for burn wounds.J Burn Care Res. 2023;44(Suppl 1):S26-32. Disponibleen: https://doi.org/10.1093/jbcr/irac131

  13. Abrego MO, Sánchez Saba J, Zaidenberg EE, Rellán I,Donndorff A, Gallucci G, y colaboradores. Uso de la matrizdérmica acelular para el tratamiento de zonas críticasen defectos de cobertura. Rev Asoc Argent Ortop Traumatol.2021;86(2).

  14. Márquez Espriella J, y colaboradores. Management of complexwounds with dermal substitute assisted by a negativepressure system. Mod Plast Surg. 2023;13(4):95-105.Disponible en: https://doi.org/10.4236/mps.2023.134010

  15. Stinner DJ. Improving outcomes following extremitytrauma: the need for a multidisciplinary approach. MilMed. 2016;181(Suppl 4):26-9. Disponible en: https://doi.org/10.7205/MILMED-D-15-00511

  16. Alameddine S, Khan N, Purohit SA, Bhambri A, NerellaR. Multidisciplinary management of complex trauma andburn injuries: a case series of challenging clinical scenarios.Cureus. 2024;16(12):e76446. Disponible en: https://doi.org/10.7759/cureus.76446

  17. French J, Agius LM, Sandiford NA. Managing the multiplyinjured patient: the impact of multidisciplinary teams.Br J Hosp Med (Lond). 2019;80(12):703-6. Disponibleen: https://doi.org/10.12968/hmed.2019.80.12.703

  18. Berrones-Sanz LD. Análisis de los accidentes y las lesiones delos motociclistas en México. Gac Med Mex. 2017;153(6):-.Disponible en: http://dx.doi.org/10.24875/GMM.17002812

  19. Instituto Nacional de Estadística y Geografía (INEGI).Accidentes de tránsito terrestre en zonas urbanas y suburbanas,conjunto de datos: Accidentes terrestres. Disponibleen: https://www.inegi.org.mx/sistemas/olap/consulta/general_ver4/MDXQueryDatos.asp?#Regreso&c=13159

  20. Zuelzer DA, Hayes CB, Hautala GS, Akbar A, MayerRR, Jacobs CA, y colaboradores. Early antibiotic administrationis associated with a reduced infection riskwhen combined with primary wound closure in patientswith open tibia fractures. Clin Orthop Relat Res.2021;479(3):613-9. Disponible en: https://doi.org/10.1097/CORR.0000000000001507

  21. Foote CJ, Tornetta P 3rd, Reito A, Al-Hourani K,Schenker M, Bosse M, y colaboradores. A reevaluationof the risk of infection based on time to debridement inopen fractures: results of the GOLIATH meta-analysis ofobservational studies and limited trial data. J Bone JointSurg Am. 2021;103(3):265-73. Disponible en: https://doi.org/10.2106/JBJS.20.01103

  22. Rupp M, Popp D, Alt V. Prevention of infection in open fractures:where are the pendulums now? Injury. 2020;51(Suppl2):S57-S63. Disponible en: https://doi.org/10.1016/j.injury.2019.10.074

  23. Johansen K, Daines M, Howey T, Helfet D, Hansen ST Jr. Objectivecriteria accurately predict amputation following lowerextremity trauma. J Trauma. 1990;30(5):568-73. Disponibleen: https://doi.org/10.1097/00005373-199005000-00007

  24. Águila-Ledesma IR, Medina-Rodríguez F, Altamirano-Gutiérrez LM, Núñez-Gómez DA, Torres-González R,Pérez-Atanasio JM. Patrón de decisión quirúrgica en laprescripción de amputaciones con escala MESS en fracturasde tibia expuesta grado III-B Gustilo-Anderson. ActaOrtop Mex. 2019;33(1):2-7.

  25. Franco-Cendejas R. Vigilancia epidemiológica de la infeccióndel sitio quirúrgico en ortopedia. Ortho-tips. 2020;16(1):7-15. Disponible en: https://doi.org/10.35366/93511

  26. Akın M, Topaloğlu S, Özel H, Avşar FM, Akın T, Polat E,y colaboradores. Awareness and wound assessment decreasesurgical site infections. Turk J Surg. 2021;37(2):133-41. Disponibleen: https://doi.org/10.47717/turkjsurg.2021.5059

  27. Lee C, Rasmussen TE, Pape HC, Gary JL, Stannard JP,Haller JM. The polytrauma patient: current concepts andevolving care. OTA Int. 2021;4(2 Suppl):e108(1-6). Disponibleen: https://doi.org/10.1097/OI9.0000000000000108

  28. Cao X, Hu Z, Zhang Y, Wang P, Huang S, Zhu W, y colaboradores.Negative-pressure wound therapy improves take rate ofskin graft in irregular, high-mobility areas: a randomized controlledtrial. Plast Reconstr Surg. 2022;150(6):1341-9. Disponibleen: https://doi.org/10.1097/PRS.0000000000009704

  29. Hill DM, Hickerson WL, Carter JE. A risk-benefit reviewof currently used dermal substitutes for burn wounds.J Burn Care Res. 2023;44(Suppl 1):S26-32. Disponibleen: https://doi.org/10.1093/jbcr/irac131

  30. Abrego MO, Sánchez Saba J, Zaidenberg EE, Rellán I,Donndorff A, Gallucci G, y colaboradores. Uso de la matrizdérmica acelular para el tratamiento de zonas críticasen defectos de cobertura. Rev Asoc Argent Ortop Traumatol.2021;86(2).

  31. Márquez Espriella J, y colaboradores. Management of complexwounds with dermal substitute assisted by a negativepressure system. Mod Plast Surg. 2023;13(4):95-105.Disponible en: https://doi.org/10.4236/mps.2023.134010

  32. Stinner DJ. Improving outcomes following extremitytrauma: the need for a multidisciplinary approach. MilMed. 2016;181(Suppl 4):26-9. Disponible en: https://doi.org/10.7205/MILMED-D-15-00511

  33. Alameddine S, Khan N, Purohit SA, Bhambri A, NerellaR. Multidisciplinary management of complex trauma andburn injuries: a case series of challenging clinical scenarios.Cureus. 2024;16(12):e76446. Disponible en: https://doi.org/10.7759/cureus.76446

  34. French J, Agius LM, Sandiford NA. Managing the multiplyinjured patient: the impact of multidisciplinary teams.Br J Hosp Med (Lond). 2019;80(12):703-6. Disponibleen: https://doi.org/10.12968/hmed.2019.80.12.703




2020     |     www.medigraphic.com