A Guide To Treating Crush Injuries

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Here is a view of the surgeon measuring the compartment pressures of the foot in a patient who sustained a bulldozer crush injury.
Two dorsal incisions were used to decompress the adductor and the four interosseous compartments.
The authors used a medial-plantar incision to decompress the medial, lateral, superficial and calcaneal compartments.
This patient sustained an open crush injury to the talus when a railroad beam fell on his foot.
The patient underwent debridement with talectomy and external fixation. A muscle flap was used to cover the soft tissue defect. A tibiocalcaneal arthrodesis will follow.
This patient sustained a Lisfranc’s fracture dislocation with disruption of the midtarsus and an impaction “nutcracker” fracture of the cuboid after being involved in a boating injury.
This injury was open reduced and internally fixated. An external fixation device was used to span the cuboid fracture and maintain length.
This patient sustained a severe crushing injury to the distal tibia and fibula as well as his entire foot. The injury occurred when a 3,000 lb. steel beam fell on his lower leg.
This patient had poor vascular status to his foot. He was temporarily fixated with pins while his foot was closely monitored. He eventually required a below-knee amputation due to the severity of the trauma.
By Zach J. Tankersley, DPM, Robert W. Mendicino, DPM, Alan R. Catanzariti, DPM, and Jordan P. Grossman, DPM

Crush injuries of the foot are serious and can be difficult to manage. These complex injuries often involve soft tissue and osseous structures. Potentially devastating complications and long term sequelae can occur if these injuries are underestimated or mismanaged.1 Compartment syndrome is a serious complication that can occur with these types of injuries. Due to the high morbidity associated with crush injuries, prompt and meticulous care is essential.2
Omer and Pomerantz reported 50 percent of their patients who sustained crush injuries of the foot had residual pain or required assisted ambulation.3 Myerson, et. al., reported that 25 percent of their patients treated for crush injuries to the foot had poor results.2 When managing crush injuries, one must emphasize early recognition and treatment of compartment syndrome (see “Detecting And Treating Compartment Syndrome” below), early soft tissue coverage, and fracture stabilization.2

One should perform a thorough history and physical examination. A detailed history should include the mechanism of injury, information about the injuring object and the manner in which the foot was affected by the object. When evaluating a traumatic injury of the foot, the primary concern is assessing the patient’s neurovascular status. Then one should proceed to evaluate soft tissue injuries, noting all contusions, abrasions, lacerations and penetrations. It is critical to assess these patients for compartment syndrome. When you suspect this condition, be sure to measure compartment pressures.4 One should also obtain X-rays and/or advanced imaging to evaluate the foot for possible fractures and dislocations.

Assessing The Degree
Of The Crush Injury
A crush injury occurs when an extrinsic compressive or shear force of variable magnitude is applied to the foot over a variable period of time.1 Vora and Myerson categorized crush injuries of the foot into three distinct types as follows:

Type I occurs when the crushing object is large and heavy, and remains in contact with the foot for an extended period of time. Compartment syndrome and plantar soft tissue defects are common with this type of injury.
Type II occurs when one notes elements of laceration. These injuries are often associated with open fractures and marked soft tissue disruption.
Type III occurs when a tangential force is applied to the foot. This leads to degloving and avulsion of soft tissue. Skeletal trauma may be absent with this type of injury.1

Detecting And Treating Compartment Syndrome
Acute compartment syndrome of the foot is a potential complication of foot crush injuries. Recognizing the signs and symptoms of compartment syndrome is important. The sequelae of a missed compartment syndrome include contracture, deformity, sensory changes, weakness, stiffness, paralysis, atrophy and chronic pain.4-9 Therefore, immediate diagnosis and aggressive treatment of compartment syndrome is imperative to minimize these outcomes.
Compartment syndrome results from a decrease in compartmental volume or an increase in the contents of the compartment.10 The elevated pressures compromise local tissue perfusion, potentially resulting in permanent myoneural tissue damage.8

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