Technique Tip: Use of “Pie Crusting” of the Dorsal Skin in Severe Foot Injury

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FOOT &ANKLE INTERNATIONAL
Copyright ©2007 by the American Orthopaedic Foot & Ankle Society, Inc.
DOI: 10.3113/FAI.2007.0851
Technique Tip: Use of “Pie Crusting” of the Dorsal Skin in Severe Foot Injury
Robert P. Dunbar, M.D.; Lisa A. Taitsman, M.D.; Bruce J. Sangeorzan, M.D.; Sigvord T. Hansen, Jr., M.D.
Seattle, WA
INTRODUCTION
Severe foot trauma has been shown to have a significant
effect on patient outcomes.6–8The appropriate and timely
use of modern operative techniques in the treatment of frac-
tures and dislocations in the feet has been shown to improve
outcomes.2Because such operative procedures are contin-
gent upon having a soft-tissue envelope that is conducive to
operative fixation, the use of more biological or soft-tissue
friendly techniques is advised. Techniques that respect the
soft tissues are believed to minimize devastating complica-
tions and may improve fracture healing and, thus, overall
function.
As with other areas of the body, high-energy injuries
to the foot may carry with them a risk of compartment
syndrome. Failure to promptly and completely treat elevated
intracompartmental pressure commonly leads to significant
morbidity.4Compartment syndrome can be devastating, with
the best treatment remaining early diagnosis and avoidance of
ischemic complications. Decompressive dermatofasciotomies
for compartment syndrome of the foot have been previously
described.4
One problem with complete fasciotomies of the foot is that
the underlying closed fractures and dislocations effectively
become directly exposed open fractures. Typically, these
fasciotomy wounds retract because of associated local edema.
Commonly, days elapse before the skin can be closed
or grafted. In this time, the tissues often are colonized
with microorganisms. Thus, these already severely injured
tissues, now exposed, are at increased risk for infection
when definitive operative fixation is undertaken. The time
required until wound closure or skin graft maturity also
may make reconstruction more difficult, which may require
Corresponding Author:
Robert P. Dunbar, M.D.
Department of Orthopaedic Surgery
Harborview Medical Center/University of Washington
Box 359798
325 9th Avenue
Seattle, WA 98104
Email: dunbar@u.washington.edu
For information on prices and availability of reprints, call 410-494-4994 X226
additional tissue stripping or may predispose to a less
than anatomic reduction. The pie-crusting technique allows
expansion of the skin, decompression of the hematoma, and
an improvement in patient comfort. Further, this simple
technique eliminates the problem of skin retraction after
formal foot dermatofasciotomy that can lead to prolonged
open wounds, colonization, and increased risk of infection.
We present a simple technique using multiple parallel inci-
sions in a “pie crust” fashion that facilitates decompression
of a severely injured midfoot and forefoot with a closed soft-
tissue envelope (Figure 1). Pie-crusting of the dorsum allows
release of the hematoma and expansion of the overlying skin
while retaining an intact dermal framework without signifi-
cant retraction of the skin edges.
The use of multiple relaxing incisions is not new. Radin5
used such “lace patterning” of the skin to reduce tension
over the tibial tubercle after Maquet extensor mechanism
realignment. Distasio et al.1used multiple relaxing incisions
to close 22 acutely treated fractures in which primary wound
closure was not possible because of localized edema. In each
case, multiple additional incisions were made, facilitating
wound closure. Patients experienced no additional morbidity,
Fig. 1: Severely traumatized foot with significant edema and fracture
blisters.
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852 DUNBAR ET AL. Foot & Ankle International/Vol. 28, No. 7/July 2007
were spared prolonged periods with open wounds, and did
not require grafting or other coverage procedures. Similarly,
Motley and Holt3and later Wong et al.9described their
techniques and reported their results of meshed advancement
flaps in dermatologic surgery, with excellent results and few
complications.
Using this technique for acute trauma requires appropriate
patient selection, timing, and operative judgment. The most
appropriate patients for this technique are those with blunt or
crush injuries with extensive hematoma who present early.
After the pie crusting decompression is performed and the
hematoma is released, the foot usually is much less tense
and the skin is less blanched, less mottled, and less shiny.
If this does not occur, the foot should be evaluated for
more formal complete dermatofasciotomy. We believe that
the small incisions used allow significant decompression of
the edematous foot and may improve local circulation and
the viability of the dorsal foot skin. The marked decrease in
edema has appeared to allow earlier fracture fixation. If the
patient remains with the foot elevated, the wounds are not
dependent and the small incisions commonly are dry at 48
hours.
OPERATIVE TECHNIQUE
The patient is placed supine on the operative table with a
small bump placed under the ipsilateral buttock. Table choice
is determined by the need to treat associated injuries. No
tourniquet is used. After induction of anesthesia, the incisions
to be used for fixation of underlying fractures are marked on
the dorsum of the foot (Figure 2). Beginning on the dorsum
of the foot, in the first and second intermetatarsal spaces,
multiple, 3 to 5 mm skin incisions are made with a #15 blade
through skin only at 10- to 20-mm intervals in a longitudinal
fashion (Figure 3). Four or five incisions are made in each
longitudinal row. A second line of similar incisions is made
in line with the fourth ray. A third row is made between the
Fig. 2: Foot marked for pie-crusting.
Fig. 3: Appearance of foot after spanning external fixation and pie-crusting
to allow decompression of large hematoma.
Fig. 4: Appearance of foot 2 weeks after injury, with healed pie-crusting
incisions, ready for definitive fixation.
first two rows. These incisions are of similar size and spacing,
but can be placed such that they are staggered longitudinally
from the other lines. Line four is made in a similar manner
but is placed lateral to the row positioned over the fourth
ray. If the foot is very large, additional lines can be made in
the same manner, parallel to the existing rows.
A small hemostat is placed through each incision and
spread to access the deeper tissues. A considerable amount
of fresh and clotted blood commonly is evacuated in this
manner. A complete evaluation of the entire foot is made to
determine if more incisions (e.g. medial) are required. If the
bony or ligamentous injury creates a significantly displaced
or unstable foot after reduction, provisional fixation such as
an external fixator or percutaneously placed Kirschner wires
should be considered.
A sterile dressing and a short leg splint are applied and
the affected extremity is elevated. Dressings are changed 48

Foot & Ankle International/Vol. 28, No. 7/July 2007 PIE-CRUSTING TECHNIQUE 853
hours after surgery and each 1 to 2 days thereafter. Typi-
cally, by 48 to 72 hours there is an eschar over each inci-
sion, drainage has decreased or ceased, and the incisions are
returning to a linear appearance. Formal treatment of under-
lying injuries takes place when soft-tissue conditions permit,
when there is wrinkling of the skin, and associated fracture
blisters have re-epithelialized. Incisions are commonly made
by “connecting the dots” of one or more of the rows of the
pie-crusting incisions (Figure 4).
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