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

When treating open injuries, provide appropriate treatment including antibiosis and tetanus prophylaxis. A first generation cephalosporin is indicated for minor open wounds as well as Type I and II open fractures. Recommended dosing for these patients is cefazolin 2g IV initially, followed by 1g IV every eight hours for three days.29 Aminoglycosides are recommended in addition to the cephalosporin for Type II and III open fractures and open wounds with significant dirt and debris.30 Joseph points out that there is little to no evidence that a safer, equally effective class of drug (i.e., extended spectrum cephalosporin or newer quinolone) could not be used as single agent with these injuries.22 One may add penicillin G, 10 to 20 million units IV, with farming injuries.30
You should give the appropriate antibiotic within three hours of the injury.31 Take appropriate cultures at the initial examination. However, if the patient is being taken directly to the operating room, one may obtain post-debridement cultures.

Pertinent Pointers On Debridement
And Soft Tissue Coverage
Be aware that there is an extended area of injury that is not always obvious when evaluating crush injuries.32 This extended area of damage is referred to as the “zone of injury.”1,5,23,33-36 It’s important to understand this concept so you don’t underestimate the amount of tissue damage and subsequently mistreat the patient.5 Researchers have shown that early soft tissue coverage is critical when attempting to salvage a crushed foot.37-42

Early debridement and soft tissue coverage provide a lower infection rate and enhanced healing.11,34,43,44 Early soft tissue coverage decreases the length of hospital stay, decreases the rate of infection, decreases the number of surgical procedures, decreases the rate of failure and increases the rate of bone union.1,5,38 One must debride all non-viable tissue before performing definitive wound closure or coverage. It may be necessary to perform serial debridements, which you would perform until the wound is completely clean. Take care to preserve vital structures during debridement.1 You should sharply transect nerves that are non-salvageable and bury them in muscle to prevent a painful neuroma.1 Make sure you cover the tendons and preserve the paratenon in order to prevent desiccation and facilitate the acceptance of a skin graft.5
It is important to delineate vitalized from non-vitalized tissue so you can perform an accurate debridement. There are several ways to delineate this zone of injury. Visual inspection using conventional parameters such as bleeding, color, contractility and consistency is satisfactory but can lack accuracy.1,45

Flourescein labeling and split-thickness skin excision (STSE) are more accurate methods of determining tissue viability and predicting flap survival. 5,10,32,46-48 Flourescein is a phenolphthalein dye that fluoresces when exposed to ultraviolet light in the presence of an intact capillary circulation.46-48 However, be advised that flourescein testing can be an unreliable modality in certain situations (i.e., A-V shunting).27
The technique of STSE has become a useful tool in determining tissue viability as well as a method of providing graft material for early soft tissue coverage.6,10,32 One would perform a STSE by harvesting a split-thickness skin graft (STSG) from the potentially non-viable skin flap and adjacent normal skin. Dermal capillary bleeding indicates skin viability. You would proceed to debride the non-viable skin flap, mesh the skin graft 1:1.5 and reapply it to the devoid area. One cannot perform this technique over areas unsuitable for STSG such as exposed bone and non-viable deep tissue.5,6,10,32 Other forms of soft tissue coverage that have been recommended include full-thickness skin grafting (FTSG), free flap reconstruction and revascularization of the degloved tissue. 49-52

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