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Evidence-Based Medicine: Lower Extremity Acute Trauma

Hallock, Geoffrey G. M.D.

Plastic and Reconstructive Surgery: December 2013 - Volume 132 - Issue 6 - p 1733–1741
doi: 10.1097/PRS.0b013e3182a80925
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Learning Objectives: After studying this article, the participant should be able to: 1. Understand the steps for evaluation of a patient with a lower extremity wound before initiating medical or surgical intervention. 2. Acknowledge that limb amputation and salvage can both be appropriate definitive treatment options. 3. Select proper nonsurgical or surgical techniques for wound management. 4. Appreciate the difference in the expected outcome according to the perspective of the physician versus the patient.

Summary: Lower extremity acute trauma is a common occurrence. Ultimate functional outcomes are similar whether amputation or salvage by limb reconstruction is the treatment pathway chosen. The reconstructive surgeon must be knowledgeable enough to assist in making the correct decision for either option. Débridement is the cornerstone of management before embarking on definitive wound closure. Nonsurgical devices have provided a transition to optimize the wound, sometimes even replacing or lessening the need for vascularized tissues to permit this coverage. Nevertheless, flaps will always have a role varying according to the involved region of the lower extremity. Traditional muscle flaps can often today be supplemented by the use of perforator flaps. The latter have great versatility as pedicled flaps for all zones of the lower limb, in addition to being a dependable free flap alternative. Horrendous injuries can now be expected to be salvaged, with a reasonable aesthetic result possible and with minimal donor-site morbidity. Preferences by both physicians and patients tend to favor the course to limb salvage, but it must be appreciated by the caregiver that it is always the patient who has to live with the residua of an altered limb and lifestyle.

Supplemental Digital Content is available in the text.

Bethlehem and Allentown, Pa.

From the Division of Plastic Surgery, St. Luke’s Hospital; Sacred Heart Hospital; and Lehigh Valley Hospital.

Received for publication March 30, 2012; accepted July 3, 2012.

Presented in part at the Tenth Annual John Knowles Swinburne Memorial Lecture, Nassau University Medical Center, in East Meadow, New York, May 8, 2010; the Fourth Annual QMP Reconstructive Surgery Symposium, in St. Louis, Missouri, November 29 through 21, 2010; the Pre Sixth Congress of the World Society for Reconstructive Microsurgery, in Bucharest, Romania, June 25 through 27, 2011; the Sixth Conference of the World Society for Reconstructive Microsurgery, in Helsinki, Finland, June 29 through July 2, 2011; and the Fourth Annual Mayo Clinic/Chang Gung University Symposium in Reconstructive Surgery, in Rochester, Minnesota, May 31 through June 3, 2012.

Disclosure: The author has no financial interest to declare in relation to the content of this article.

Supplemental digital content is available for this article. Direct URL citations appear in the text; simply type the URL address into any Web browser to access this content. Clickable links to the material are provided in the HTML text of this article on the Journal’s Web site (

Geoffrey G. Hallock, M.D., 1230 South Cedar Crest Boulevard, Suite 306, Allentown, Pa. 18103,

©2013American Society of Plastic Surgeons