Lawnmower Case Study

Question 1

what was the zone of the foot we studied?

Answer 1

forefoot = zone 1.

primarily looked at the hallux.

Question 2

what labs would be gather and what might they show?

Answer 2

he was on Plavix- make sure he has not lost too much blood.
WBC- infection possible
INR- how well is he clotting. ( important to know for surgery candidates)

Question 3

what are the most common injuries with lawnmower accidents?

Answer 3

fractures, toe amputations and lacerations/burns

Question 4

What is the 1st zone of injury?

Answer 4

1. foreffoot ( which is what half of lawnmower injuries involve)… primary closure needed.

Question 5

what is the second zone of injury?

Answer 5

2. midfoot.

need to have primary closure and possibly flaps/grating.

Question 6

3rd zone of injury?

Answer 6

mid plantar. ( you may need a flap on this one)

this is on the side by the 5th metarsal

Question 7

what is the 4th zone of injury?

Answer 7

heel plantar

Question 8

what is the 5th zone of study?

Answer 8

ankle

Question 9

What is recommended in terms of closing a laceration?

Answer 9

primitive closure before full surgery or debridement.
if even laceration occurred 6 hours or more ago- then debride and wait to close.
open wound infection rate = 17%
closed wound infection rate - 11%

Question 10

what is recommended in terms of antibiotics?

Answer 10

the sooner the better.
combo therapy ( Cephalosporin and aminoglycoside) did better than just Cipro ( has broad spectrum, but lacks in specific areas that the combo achieves)
farm injuries- need the strongest thing microbes more common. ( ampicillin, penicillin, clinda)

Question 11

External fixation vs internal?

Answer 11

external is better- less likely will cause infection. however there is potential for arthritis later. oftentimes fixation is needed when we have many small fragments of a bone. this is used when bone fragments are displaced.

Question 12

What color should metal show up on an XR?

Answer 12

bright white

Question 13

what do we want tissue to look like…

Answer 13

near the scar it should be pink - shows good vascularization and good healing ( white is not so good)
tissue should look beefy- this is preferred. if it is purple we wont be trying to save it- dead.

Question 14

how does plavix complicate treatment?

Answer 14

this is a blood thinner. can cause patient to bleed more than expected, prevents platelets from sticking together. be prepared to lose more blood in surgery. important to control bleeding to reduce hemorrhage and edema at wound site. overall less likely to clot. Plavix has a half life of 7 days… may prevent the patient from going into surgery right away. ( THIS PATIENT WAS DELAYED- for primary right hallux closure)

Question 15

tell me more about bone management?

Answer 15

**if operation will be needed.
you can remove loose free cortical bone fragments that have surfaced and dont have soft tissue attachments
bone can be stabilized with wires, screws,
K wire
many fragments that are displaced- use external fixation.
post op = CAM boot.
***however, in the case- leave it along, there are many fragments but they arent really displaced.

Question 16

More specifically, how is the soft tissue managed?

Answer 16

sutures- need to be done in 6 hour time frame. oftentimes you can rinse and close, or you can leave it open until surgery and use bandaged in the meantime to cover. ( if not irrigated/debrided within 6-8 hours, wait!!!)
wait to close for 3-7 days…unless you have an exposed tendon/nerve or bone
( we want to wait in order to monitor infection, receive flaps)
if alot of skin is lost, use a graft
the nail avulsion can be lavaged ( washed out).
remove nonviable/contaminated tissue
need to make sure their isnt nerve damage
also check tendons and ligaments

Question 17

how should the soft tissue be washed out?

Answer 17

use 1L saline.

• make sure to do continuous debridements until the official closure can be done
• make sure to remove foreign bodies ( oftentimes this needs to be done in surgery- otherwise too painful).

Question 18

most common route of lawnmower injuries?

Answer 18

patient pulling backwards and falls , mower comes with
men more often ( 5.3x more likely to be hospitalized)
74,000 ER visits a year

cause toe amputations/fractures. as well as lacerations and burns.

Question 19

Medications prescribed?

Answer 19

initially: IV Rocephin (cephalosporin antibiotic) and Tetanus prophylaxis (vaccine)
sent home: Vicodin and Keflex ( cephalosporin antibiotic)
returned due to pain and bleeding.
next: IV Zosyn ( antibiotic)
post op: vicodin, augmentin for 10 days
( discharged from hospital after 2 days and was nonweightbearing in boot/crutches)

Question 20

post surgical…

Answer 20

1 month: wound dehisced due to fibrotic white base ( debride ulcer to granular base)… this is when panafil was used .
(Panafil ointment is a debriding agent. It works by helping the breakdown of dead skin and pus, which helps improve the recovery time of open wounds. It also helps to control wound inflammation and odor.)

Question 21

riding vs push mowers?

Answer 21

more commonly occur with push mowers, however riding mowers cause worse injuries.
higher # of injuries in the 70’s until safety was enacted in the 80’s.
children are affected- fall off riding mowers, also are not seen and can be run over.

Question 22

common mechanisms for mower injuries… other body parts

Answer 22

13% eye
11% hand ( changing blade while not even running)
7% falling or slipping
5% loading or unloading lawn mower
3% running mower over limb

Question 23

frequency of lawn mower lower extremity issues?

Answer 23

fractures of more than 1 phalanges = 34%
amputation of toe = 32%
fracture of tarsal bones = 15%
open wound = 11%

Question 24

what are the Gustilo and Anderson Classifications?

Answer 24

Gradation of lacerations/wounds based on the extensive tissue damage, soft tissue coverage, contamination. lower the number, not as severe. most infection seen in those that are contaminated, have exposed bone, aterial injury and less soft tissue to cover.

Question 25

summary

Answer 25

lawnmower accidents usually affect the foot and ankle, specifically the toes.
early antibiotic use, irrigation and debridement are essential!