Demographics • 60000 ED visits per year • 75 deaths annually • 7% require hospitalization • 2-5 surgeries per injury • 64% require amputation • $457 million annually • Prosthetic costs of $73140 to $116040 from the time of injury
to the age of 18 • 18.9% of all injuries are to the lower extremities • 50% of amputation from lawn mower injuries occur in the foot
Demographics • 58-77% males • Age <14 and >44 years old • 20% are in children under 18 years old • 11.9/100000 children • 2000 children permanently impaired per year.
Recommendations • American Academy of Pediatrics and the United States
Consumer Product Safety Commission. • Children less than 14 years of age should not be allowed to
operate ride-on lawn mowers • Adolescents should be trained in the use of these tools
before independent use. • Young children, especially those 5 years or younger, should be
kept indoors when a lawn mower is in use. • Continue to develop safety devices that will reduce the risk of
injury to all lawn mower users.
Regulations • Deadman’s switch
• Required in July of 1982 • Decreased lawn mower related injury by 40%
• Riding mower
• Operator presence control • Higher seat back
Mechanism of Injury • Blade spins at 3000 RPM • Equivalent of dropping 211 lb weight 100 ft
• 3x the power of a .357
• 51% pulling mower backwards • 24% pulling mower up a slope
Types of injury • Laceration 41%
• 71% occurring on the hands or feet • Soft tissue 21.4% • Burn 15.5% • Fracture 10.3% • Missile injury 5-9%
Types of injury • Anger DM
• 33 patients • 40 open fractures • 20 amputations • 18 lacerations involving skin and nail bed • 9 tendon lacerations • 2 closed fx • 2 segmental loss of bone • 1 segmental achilles
Evaluation • Soft tissue • Osseous involvement • Thorough exam (may need to use local anesthesia) • Remove debris and contaminates
Tetanus • Tetanus immune globulin is administered in the event a child
has not received a minimum of three doses of tetanus toxoid, or if the immunization status is unknown. Tetanus toxoid (dT, DT, or DTaP) also is given in this situation.
• A booster dose should be administered if the child has not received a dose of tetanus toxoid in the last 5 years.
Treatment • Intraoperative cultures
• Aerobic, anaerobic, fungal, and acid-fast organisms • Open fractures -> bone biopsy
• Immediate and vigorous surgical debridement • Pulse lavage as soon after the injury as possible
Infection • Campbell • Meta-analysis • 9 studies, 355 cases • 5-60% of injuries became infected
• Anger • Mean of 3 infecting organisms
Organisms • Harkness • Fertilizer • Enterobacter spp, E. coli, Klebsiella spp, Serratia spp, Citrobacter spp
• Environmental gram negative • Enterobacter spp, E. coli, Klebsiella spp, Serratia spp, Citrobacter spp
• Gram Positive • Enterococcus , coagulase negative Staphylococcus Staphylococcus
aureus
• Soil related anaerobes • Clostridium spp and Bacteroides spp
• Fungal infection has also been reported
Antibiotics • Traumatic contaminated wounds • Danger
• Ciprofloxacin first line • Bactrim second line • Ceftazidime in children
• Anaerobes • Penicillin G or Clindamycin
• Absence of infection • Abx course for 5-10 days
Antibiotics cont. • Therapeutic Guidelines: Antibiotic • Initiate monotherapy with zosyn or timentin
• or clindamycin combined with either gentamicin or ciprofloxacin
• For heavily soiled wounds: recommend initial therapy with vancomycin, imipenem and an aminoglycoside
• Fungal infection amphotericin B or voriconazole
• Modify once cultures become available.
Antibiotics cont. • Gustillo and Anderson • I. Clean Wound <1cm in diameter
-Abx choice: 1st generation cephalosporin (Ancef) • II. Wound 1.0-5.0cm in diameter with minimal soft tissue
damage -Abx choice: Ancef, Clindamycin • III. Wound >5cm in diameter with extensive soft tissue
damage -Abx choice: Ancef (or high dose PCN), Clindamycin and Aminoglycoside
Treatment cont. • Love
• 2nd intra-operative debridement 24-72 hours after injury. • Planned delayed closure
• Graham • 28 Pts • “multiple debridement with irrigation”
• Peterson • Multiple debridement necessary
• Ryan and Hume • 6 cases • Primary closure is contraindicated
• Myerson 1991 • under no circumstances should the skin be closed before 5-7 days
Treatment cont. • Corcoran
• 96 wounds in 70 patients • Primary closure does not increase chance of infection
• Anger • No difference between primary closure and secondary closure in
regards to infection • Goldsmith
• 9 patients • Advocated for primary closure of digits and NWB surfaces.
Treatment Cont. • Laing • Split skin grafting in 17 patients, • Local fasciocutaneous flap reconstruction in 3 patients • Microvascular free tissue transfer in 3 patients to reconstruct
amputated heels • 2 free latissimus dorsi flaps and • 1 free thoracodorsal artery perforator flap.
Case • 19 year old active duty male presents to the ED with right
hallux wound secondary to a lawnmower injury. Pt was wearing military boots while mowing on a hill and slipped with his right foot ending up under the mower.
History • PMH: denies
• Meds: denies
• Social History
• Current smoker 1 pack year hx • Denies alcohol • 11 Bravo (infantry)
• ROS unremarkable except what was mentioned above
Plan • Irrigation • Wound dressed and posterior splint applied • NWB to right lower extremity • Ancef 1gm q8h • Surgery in the AM
Discharge • Augmentin 125/875 BID • Gram stain – no organisms seen • Pre-irrigation cultures – results unavailable • Post-irrigation cultures showed no growth
References • Anger DM, Ledbetter BR, Stasikelis PJ, Calhoun JH. Injuries of the foot related to the use of
lawn mowers. J Bone Joint Surg Am. 1995;77(5):719-25. • Brook I. Recovery of anaerobic bacteria from wounds after lawn-mower injuries. Pediatr
Emerg Care. 2005;21(2):109-10. • Campbell JR. Infectious complications of lawn mower injuries. Pediatr Infect Dis J.
2001;20(1):60-2. • Corcoran J, Zamboni WA, Zook EG. Management of lawn mower injuries to the foot and
ankle. Ann Plast Surg. 1993;31(3):220-4. • Costilla V, Bishai DM. Lawnmower injuries in the United States: 1996 to 2004. Ann Emerg
Med. 2006;47(6):567-73. • Erdmann D, Lee B, Roberts CD, Levin LS. Management of lawnmower injuries to the lower
extremity in children and adolescents. Ann Plast Surg. 2000;45(6):595-600. • Goldsmith JR, Massa EG. Primary closure of lawn mower injuries to the foot: a case series. J
Foot Ankle Surg. 2007;46(5):366-71. • Greenhagen RM, Raspovic KM, Crim BE, Ryan MT, Gruen GG. Lawn mower injuries to the
lower extremity: a 10-year retrospective review. Foot Ankle Spec. 2013;6(2):119-24. • Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and
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References cont • Harkness B, Andresen D, Kesson A, Isaacs D. Infections following lawnmower and farm
machinery-related injuries in children. J Paediatr Child Health. 2009;45(9):525-8. • Loder RT, Dikos GD, Taylor DA. Long-term lower extremity prosthetic costs in children with
traumatic lawnmower amputations. Arch Pediatr Adolesc Med. 2004;158(12):1177-81. • Lau ST, Lee YH, Hess DJ, Brisseau GF, Keleher GE, Caty MG. Lawnmower injuries in children:
a 10-year experience. Pediatr Surg Int. 2006;22(3):209-14. • Laing TA, O'sullivan JB, Nugent N, O'shaughnessy M, O'sullivan ST. Paediatric ride-on mower
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