Management of Laceration on the Leg with Bone Exposure
A laceration on the leg with bone exposure requires immediate surgical intervention for wound debridement, irrigation, and appropriate coverage to prevent infection and optimize functional outcomes.
Initial Assessment and Management
Immediate Actions
- Control bleeding with direct pressure
- Assess neurovascular status of the limb
- Evaluate for associated injuries
- Immobilize the extremity in the position found 1
- Cover the wound with a sterile dressing 1
Risk Assessment
- Evaluate hemodynamic stability
- Check tetanus immunization status and provide prophylaxis if needed 1
- Assess for risk factors that may complicate healing:
- Diabetes
- Contamination
- Wound size >5 cm
- Lower extremity location (higher infection risk) 2
Definitive Management
Surgical Intervention
Wound irrigation and debridement
- Thorough cleaning of the wound
- Removal of devitalized tissue
- Exploration of wound to assess depth and involvement of structures 1
Bone management
- Assessment of periosteal integrity
- Removal of devitalized bone if present
- Obtain bone specimen for culture and histopathology if infection is suspected 1
Fracture stabilization (if present)
- External fixation is preferred for temporary stabilization of associated fractures
- Allows wound access and facilitates soft tissue management 3
Soft tissue coverage
- Primary closure if possible
- Consider artificial dermis for bone-exposed wounds (91% take rate reported) 4
- Skin grafting may be necessary for larger defects
- Negative pressure wound therapy may be considered for complex wounds
Antibiotic Management
- Administer antibiotic prophylaxis as soon as possible for open fractures 1
- Continue antibiotics for 48-72 hours (unless proven infection requires longer treatment) 1
- For simple lacerations without bone involvement, prophylactic antibiotics may not be necessary
Pain Management
- Topical anesthetics (LET: lidocaine, epinephrine, tetracaine) for initial pain control 1
- Consider buffered lidocaine for local anesthesia during wound management
- Systemic analgesia as appropriate based on pain severity
Follow-up Care
Wound Monitoring
- Regular assessment for signs of infection:
- Increasing pain
- Erythema
- Purulent drainage
- Fever
Rehabilitation
- Early mobilization when appropriate
- Physical therapy to maintain range of motion and strength
- Gradual return to weight-bearing activities as healing progresses
Special Considerations
Infection Risk
- Lower extremity lacerations have 4.1 times higher risk of infection 2
- Contaminated wounds have twice the risk of infection 2
- Lacerations >5 cm have 2.9 times higher risk of infection 2
- Diabetic patients have 2.7 times higher risk of infection 2
Amputation Considerations
- No single severity criterion mandates amputation
- Decision should be based on comprehensive assessment of:
- Patient stability
- Warm ischemia time
- Soft tissue coverage possibilities
- Neurovascular status 3
Common Pitfalls to Avoid
- Delaying surgical intervention for bone-exposed wounds
- Inadequate debridement of devitalized tissue
- Failure to recognize compartment syndrome
- Underestimating the severity of soft tissue injury in crush mechanisms
- Inadequate pain management during procedures
- Insufficient wound irrigation and cleaning
- Overlooking the need for tetanus prophylaxis
The presence of "burst lacerations" (lacerations of webbed spaces or along medial/plantar surfaces) should alert clinicians to high-energy crush injuries that may have more extensive soft tissue damage than initially apparent 5.