Primary Closure of Lawn Mower Injuries to the Foot: A Case Series
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Primary Closure of Lawn Mower Injuries to
the Foot: A Case Series
Jon R. Goldsmith, DPM,1 and Eric G. Massa, DPM, FACFAS2
The standard initial treatment of lawn mower injuries to the foot consists of prompt administration of
parenteral antibiotics, debridement of devitalized tissue, irrigation, repair of traumatized vascular struc-
tures, and stabilization of osseous fractures. The primary closure of these wounds at the initial operation
is a controversial concept. The authors performed a retrospective study of 9 lawn mower injuries in which
primary closure was performed. Medical records were evaluated, and 7 patients were reached for
follow-up interviews. The hospital courses for this patient population were remarkably lower than those
previously reported in the literature. No patient required further admission to the hospital or surgical
intervention. The postinjury functional evaluation mean score was 97.6%. The results demonstrate that
this treatment method can be an effective means for treating this mutilating injury in the foot. ( The
Journal of Foot & Ankle Surgery 46(5):366 –371, 2007)
Key words: lawn mower injuries, mutilating injuries, amputation
I njuries caused by lawn mowers are associated with severe oped these safety guidelines, the number of injuries due to
lawn mowers has minimally increased, appropriately corre-
mutilation and long-term disability. In the year 2000, there lating with the increase in lawn mower ownership.
were a reported 80,000 injuries associated with power Physicians have been treating lawn mower injuries for
mowers (1). These injuries included missile injuries, gaso- over 60 years, but an agreed-upon treatment protocol for
line burns, hand trauma, and visceral trauma (2–7). How- wound closure is absent from the medical literature. Many
ever, more than two thirds of these injuries involved the different types of surgeons, including podiatric surgeons,
lower extremity (8). In a multicenter study of 553 patients, orthopedic surgeons, pediatric orthopedic surgeons, plastic
66% involved trauma to the toes or feet (9). surgeons, and trauma surgeons, treat these injuries. This has
In the year 2000, more than 6,000,000 walking mowers resulted in many different protocols. The most medically
and 1,700,000 riding mowers were shipped from manufac- effective and cost-efficient method of treatment has never
turers to retailers (1). The type of mower has little conse- been researched.
quence when discussing the wounding capabilities of the The authors treat this injury with prompt antibiotic prophy-
machine. The average blade is 26 in long and weighs 3.5 lb. laxis, surgical debridement, irrigation, repair of vascular
The wounding capability of this blade moving at the stan- trauma, stabilization of osseous fractures, and frequently pri-
dard 3000 rpm is equivalent to dropping a 211-lb object mary closure. The authors have reviewed all of the lawn
from the height of 100 ft (10, 11). This is 3 times the muzzle mower injuries that have presented to the Grant Medical Cen-
energy of a .357 Magnum pistol (11). ter’s and Doctor’s Hospital’s podiatry service to evaluate the
During the 1950s and through the 1970s, there was a treatment and critique the protocol for future encounters.
plethora of descriptions of injuries and demands for preven-
tative measures in the medical literature (2, 10, 12–20).
Federal standards for guiding the designing of walking- Materials and Methods
power mowers were instituted in 1982, and similar stan-
dards were adopted for riding mowers in 1987. Since the The records of patients treated for lawn mower injuries
United States Consumer Product Safety Commission devel- by the podiatry service at Grant Medical Center and Doc-
tor’s Hospital from 2003 to 2005 were reviewed. Patients
were identified, and their outpatient records were reviewed.
Address correspondence to: Jon Goldsmith, DPM, Foot and Ankle Patients’ records were used to identify those treated with
Center of Nebraska, 7337 Dodge St, Omaha, NE 68114. E-mail: antibiotic prophylaxis, surgical debridement and irrigation,
jonrgoldsmith@hotmail.com.
1
PGY-3, Chief Resident, Grant Medical Center, Columbus, OH; and and primary closure. The exclusion criterion was any patient
Foot and Ankle Center of Nebraska, Omaha, NE. whose wound was not closed at the initial surgical interven-
2
Tifton Foot & Ankle, Tifton, GA. tion. Injuries were stratified by anatomic zones by a previ-
Copyright © 2007 by the American College of Foot and Ankle Surgeons
1067-2516/07/4605-0007$32.00/0 ously published method that was specifically designed for
doi:10.1053/j.jfas.2007.06.003 this form of injury (21). These zones (Figure 1) were
366 THE JOURNAL OF FOOT & ANKLE SURGERYTABLE 1 Functional evaluation questionnaire
Category Score
Pain 4 None
3 Mild/intermittent
2 Severe/frequent
1 Severe/daily
Activity level 3 No restriction
3 Recreational/sports restriction
2 Limited daily activities
1 Total disability
Walking capacity 4 Unlimited
2 Limited
1 Inside only
1 Unable
Gait abnormality 4 None
3 Minor cosmetic limp
FIGURE 1 Anatomical Zone Classification of lawn mower injuries
2 Major cosmetic limp
of the foot (after Corcoran, Zamboni, and Zook).
1 Major handicap
Walking aids 2 None
divided into: zone I, the digits; zone II, the dorsum; zone III, 1 Shoe insert/special shoes
1 Orthotic/prosthetic
the plantar non-weight bearing surface; zone IV, the heel; 1 Cane/crutches/wheelchair
and zone V, the ankle. Each patient’s details of the injury, Wound complications 1 None
hospital course, outpatient course, method of treatment, 1 Skin problems
timing of treatment, and complications were recorded in 2 Rare ulcerations
addition to general demographic data. 1 Frequent ulceration
Patients available for follow-up were evaluated by tele-
phone. For this group of patients, further data were collected
concerning chronic disability and function. This informa-
and debridements. The 9 patients included in the study had an
tion was used to score the functional outcome by a previ-
absence of gross contamination after debridement and irriga-
ously published standardized means in regards to lawn
tion, and their wounds were primarily closed intraoperatively.
mower injuries (22). Questions examined pain, daily activ-
Seven of these patients were reached by telephone during
ity level, walking endurance, gait abnormalities, use of
which additional information was ascertained regarding their
walking aids, and wound complications (Table 1). Each
chronic conditions.
category was scored from 0 to 4, with a maximum total
At the time of injury, patients were evaluated in the
score of 24 points. Results were assessed by the outpatient
emergency department, and 8 were admitted for treatment.
course and functional outcome score.
Of the 8 who were admitted, the average hospital stay was
2 days (range, 1-3 days). All 9 were men, and the average
Results age was 35.1 years (range, 16-54 years) at the time of the
accident. All patients were experienced operators, and no
Twelve patients on the podiatry services at Grant Medical patient admitted to previous injury using a lawn mower.
Center and Doctor’s Hospital were identified as having lawn Eight of the 9 injuries were the result of push mowers.
mower injuries from 2003 to 2005. Nine of those were treated One was the result of a riding mower. Tractor attachment
promptly with parenteral antibiotic prophylaxis, surgical de- mowers did not cause any of the injuries reported in this
bridement of devitalized tissue, copious irrigation, repair of study. At the time of the accident, 4 patients reported that
vascular trauma, stabilization of osseous fractures, and primary the surface they were cutting was dry. Two patients reported
closure of wounds at the initial surgical intervention. Their the surface was damp, and 3 could not recall the condition.
results are summarized in Table 2. The other 3 patients were All but 1 patient were wearing athletic shoes without cleats,
excluded from the study because of alternative treatment re- and the remaining patient reported not wearing any shoes.
garding wound closure. One of the patient’s injuries involved Four patients reported that their injury occurred in the
the calcaneus and Achilles’ tendon associated with intense afternoon (12:00 PM-5:00 PM). Three patients reported that
debris within the wound, and the attending surgeon was not the accident occurred in the evening (5:01 PM-8:00 PM), and
comfortable with primary closure. The other 2 cases involved 2 patients reported that the accident occurred at night
injuries that occurred at 9 and 11 hours before the initial (8:01 PM-10:00 PM). Six patients reported arriving at the
surgical debridement, and, in both cases, the attending sur- hospital less than 30 minutes after the injury occurred. The
geons elected delayed primary closure after multiple irrigations remaining 3 reported the time to arrival at the hospital was
VOLUME 46, NUMBER 5, SEPTEMBER/OCTOBER 2007 367TABLE 2 Subjects’ treatment and results
Subject Time from Injured anatomy Procedure performed Cultured species Antibiotic and length of Functional
injury to use Outcome
operating Score
room
1 Soft tissue laceration Irrigation and closure No culture Amoxicillin-clavulanate,
10 d
2 ⬍6 h Tendon and bone Hallux amp and partial No culture Clindamycin, Ciprofloxacin, 24
2nd amp 14 d
3 ⬍8 h Phalanx Fx Partial amp Staphylococcus Clindamycin, Ciprofloxacin, 24
epidermidis, 10 d
Psedomonas
fluorescens
4 ⬍6 h Phalanx Fx Irrigation and ORIF No growth Clindamycin, Ciprofloxacin, 23
10 d
5 ⬍12 h Multiple phalanx Fx Partial amp Enterobacter Cefazolin, Cephalexin, Pen 24
cloacae G, Gentamicin, 14 d
6 ⬍6 h Severed dorsal tendons Irrigation with ORIF No culture Imipenum-cilastatin, 56 d 21
and neuro-vascular
bundle, multiple Fx
7 ⬍6 h Multiple phalanx Fx Irrigation and comp No growth Cefazolin, 10 d 23
leted amps
8 ⬍6 h Multiple Phalanx Fx Completed amp P. aeruginosa Pen G, cefazolin, 10 d
9 ⬍6 h Phalanx Fx Irrigation and hallux Pipercillin-tazobactum, 22
amp 30 d
Abbreviations: amp, amputation; Fx, fracture; ORIF, open reduction with internal fixation.
FIGURE 2 Patient with type II injury showing severance of 5 of 6 extensor tendons, the dorsalis pedis artery, and the majority of the dorsal
cutaneous nerves.
less than 60 minutes. All patients in this study denied being patient had significant tendon injury or neurovascular com-
under the influence of drugs or alcohol at the time of injury. promise. Osseous injuries involved both single fracture
Injuries were classified by location (21), and it was found lines and multiple fracture lines and comminution.
that there was a total of 8 type I injuries, 1 type II injury, and Two patients were treated at outlying hospitals before being
1 type III injury (Figure 1). All but 1 patient had osseous transferred to the authors’ facilities. All patients received ap-
trauma. The patient with the type II injury had severed 5 of propriate tetanus prophylaxis in the emergency department.
6 extensor tendons, the dorsalis pedis artery, and the ma- Two patients’ wounds were flushed in the emergency depart-
jority of the dorsal cutaneous nerves (Figure 2). No other ment with high-powered pulsed lavage. One of these patient’s
368 THE JOURNAL OF FOOT & ANKLE SURGERYTABLE 3 Chronic postinjury sequelae *(nⴝ7) irrigation. The concept of primary closure for such injuries
remains controversial throughout the medical literature.
Complaint Number of patients
In the 1970s, several authors suggested treatment strategies
Pain 3 for treating such injuries. Graham et al reported on 28 patients,
Loss of sensation 4 and these authors promoted the concept of multiple debride-
Reduction in range of motion 4 ments with irrigation of the wounds (8). Peterson et al authored
Sense of balance compromised 1
a case presentation and postulated that appropriate treatment
*One patient required occasional use of acetaminopher for consisted of antibiotics and skin coverage after multiple sur-
analgesia. gical debridements (23). Ryan and Hume reported on 6 cases
of lawn mower injuries and wrote “primary wound closure is
contraindicated in this type of wound” (19).
wounds did not involve bone injury. This patient’s wounds
Myerson agreed with the idea of multiple debridements
were closed in the emergency department, and he was dis-
and stated so in 1991 (24). He advocated prompt surgical
charged with prophylactic antibiotics. All patients were started
treatment and packing of the open wounds. He stated that
on parenteral antibiotics in the emergency department. Seven
“under no circumstances should the skin be closed before
patients had their antibiotic changed at least once before hos-
5-7 days.” He wrote that the reason for this schedule was
pital-based care was complete. One patient was discharged on
because “the incidence of infection in wounds closed pri-
parenteral antibiotics, and 8 patients were discharged on oral
marily is unacceptably high.”
agents. Patients remained on antibiotics an average of 18.2
Alonso and Sanchez reported on 33 pediatric lawn mower
days (range, 10-56 days). Two patients had infectious disease
injuries and also concluded that these injuries necessitated
specialist consults performed.
multiple surgical procedures (25). Despite their cautious treat-
Of the 8 patients who went to the operating room for
ment regimen, 2 cases went on to develop osteomyelitis.
debridement and closure, 7 were within 6 hours of the
Not all reports have condemned the concept of using
injury. The remaining patient went to the operating room
primary closure in the treatment of lawn mower injuries. In
within 12 hours of injury. All 8 patients who were admitted
1993, Corcoran et al reported on their experience treating 70
went to the operating room and underwent 1 surgery to
patients with foot and ankle injuries attributed to lawn
resolve their injury. Fracture care included open reduction
mowers (21). The authors divided the foot into anatomical
and internal fixation, removal of comminuted fragments,
zones and then reevaluated their patients and postinjury
and or amputation at the fracture site. No injury required
course at an average of 31 months. Treatment consisted of
spanning with internal or external fixation.
both open and closed regimens. Their results indicated that
Preoperative cultures were obtained for 1 patient. Intra-
certain zones of the foot could be treated with primary
operative cultures were obtained for 5 patients. The protocol
closure without increasing the rates of complications and
for cultures was different for patients because of the mul-
infection. They concluded that “despite the contaminated
tiple attending surgeons.
environment” involved in all of these types of injuries,
The average number of outpatient visits was 3 (range, 2-4
“these wounds can be closed safely with an infection rate
visits). No patient required readmission or further surgery.
that does not differ from open treatment.”
Chronic complaints included reduced range of motion at
A couple years later, Anger et al published their results
affected joints and decreased sensation (Table 3). One pa-
treating foot injuries caused by lawn mowers (26). Although
tient reported difficulties with balance. No patients required
they focused on the prophylactic antibiotic choice, it is noted that
the use of a prosthesis. No patient acquired a postoperative
they primarily closed 10% of the injuries and did not report a
infection. One patient required occasional medicine (acet-
difference between the closed or open patient populations.
aminophen) for chronic pain. Patients reported an average
The data presented in this article support the concept of
of 3.8 weeks (range, 2-6 weeks) lost from work. The aver-
primary closure for lawn mower injuries located at the
age time to follow-up was 8.4 months (range, 2-15 months).
digits, dorsum, or plantar nonweightbearing surface. All of
The 7 patients (Table 2) who were reached by telephone
the patients in this study received prophylactic antibiotics,
were evaluated with the functional evaluation questionnaire.
surgical debridement, and irrigation with primary closure of
Two patients were lost to follow-up. The average score was
the wounds. None of the 9 patients in this study were
23.0 points (range, 21-24 points), which is equivalent to
diagnosed or treated for a postoperative infection.
95.8% of the maximum number of points possible.
Hospital stays for the patients in this study were remark-
ably lower compared with data from literature advocating
Discussion multiple debridements and delayed closure (Table 4). One
such study reported a mean hospital stay of 18 days, which
It is well accepted that the surgical treatment of lawn mower is significantly high compared with the mean in this study,
injuries of the foot requires prompt debridement and copious which was found to be 2 days (19).
VOLUME 46, NUMBER 5, SEPTEMBER/OCTOBER 2007 369TABLE 4 Hospitalizations hospital stays and a quicker recovery while not subjecting
Study Year Stay in days
patients to higher rates of infection or posttraumatic compli-
mean (range) cations. The authors do not advocate this protocol for treatment
of trauma that involves injury to the ankle and weightbearing
Goldsmith and Massa 2006 2 (1-3) surface of the foot, and must be considered cautiously when
Madigan and McMahan 1979 6
Corcoran et al 1993 7.4 treating patients who are immunocompromised or were de-
Vosburgh et al 1995 11.6 layed in receiving medical care after injury.
Ryan and Hulme 1978 18
Postoperative complications that affected these patients Acknowledgment
are summarized in Table 3. At the time this study was
performed, all patients were completely healed and had The authors would like to acknowledge their appreciation to
resumed their usual daily activities. Using Vosburgh et al’s Drs. Lori DeBlasi, Michael Perez, Jonathan Wash, and Richard
functional evaluation questionnaire (22), 7 of these 9 pa- Weiner for allowing their cases to be included in the data collec-
tients were evaluated. These patients’ scores averaged 95.8%. tion and their patients contacted for follow-up evaluation.
In comparison, Vosburgh et al’s patient scores when the fore-
foot was involved averaged 88%. It is reasonable to surmise
that longer hospital stays with multiple debridements and de-
layed primary closure do not offer any advantage to short- or References
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