Is it recommended to use staples for heel lacerations?

Heel Lacerations and Use of Staples

Staples are not recommended for heel lacerations due to the high risk of pressure-related complications and poor healing outcomes in this weight-bearing area.

Rationale for Avoiding Staples in Heel Wounds

Heel wounds require special consideration due to their location on a weight-bearing surface that experiences significant pressure during ambulation. The evidence strongly suggests that staples would be problematic for several reasons:

1. Pressure and Offloading Concerns:

   • Heel wounds require effective pressure offloading to heal properly 1, 2
   • Staples create rigid pressure points that can worsen tissue damage in weight-bearing areas
   • The International Working Group on the Diabetic Foot (IWGDF) emphasizes that relief of pressure is "a cornerstone in treating ulcers associated with increased biomechanical stress" 1

2. Wound Characteristics:

   • Heel skin is thick with minimal subcutaneous tissue
   • The area is prone to hyperkeratosis and callus formation 1
   • Staples may not provide adequate tensile strength for this high-stress area

Recommended Approach for Heel Lacerations

Initial Assessment

• Evaluate wound depth, signs of infection, and vascular status by palpating dorsalis pedis and posterior tibial pulses 2
• Assess for peripheral neuropathy, which may affect healing and treatment decisions 1

Wound Management

1. Wound Closure Method:

   • Primary choice: Sutures for deep lacerations requiring closure
   • Alternative: Tissue adhesives for superficial lacerations with minimal tension
   • Avoid staples due to pressure concerns and poor outcomes in weight-bearing areas

2. Debridement:

   • Use sharp debridement to remove necrotic tissue when necessary 2
   • Consider local anesthesia if the patient has intact sensation

3. Dressing Selection:

   • Choose appropriate dressings based on wound characteristics:
     • Continuously moistened saline gauze or hydrogels for dry wounds
     • Alginates or foams for exudative wounds
     • Hydrocolloids for wounds needing autolysis 2

Critical Offloading Strategies

• Implement pressure offloading to promote healing:
  • Non-removable knee-high devices (total contact cast) when possible 1
  • Removable walkers when non-removable devices are contraindicated 1, 2
  • Consider shoe modifications, temporary footwear, or orthoses 1
  • Instruct patients to limit standing and walking, and use crutches if necessary 1

Special Considerations

Infection Prevention

• Monitor for signs of infection, which may be more common in heel wounds due to pressure and decreased circulation
• If infection develops, obtain deep tissue cultures before starting antibiotics 2
• Start empiric antibiotics targeting Staphylococcus aureus and streptococci for superficial infections 1

Follow-up Care

• Regular dressing changes to monitor healing progress
• Provide education on proper foot care and offloading techniques
• Schedule follow-up based on risk stratification:
  • Low-risk patients: annual examination
  • Moderate-risk patients: every 3-6 months
  • High-risk patients: every 1-3 months 2

Conclusion

While staples may be faster to apply in some laceration repairs 3, 4, their use in heel lacerations is contraindicated due to the unique challenges of this weight-bearing area. Proper wound closure with sutures or tissue adhesives, combined with effective offloading strategies, provides the best approach for promoting healing and preventing complications in heel lacerations.