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

Insights On Stabilizing Fractures
Crush injuries of the foot can be associated with fractures and dislocations. Surgical stabilization of fractures optimizes the overall outcomes of crush injuries.53,54 Skeletal stabilization is used not only for fracture fixation, but also for wound management.5 Rigid fixation optimizes the local conditions for wound healing and decreases infection rates by eliminating micromotion of the soft tissue, reducing edema and improving the microcirculation within the zone of injury.55 Reduction in swelling results in cellular and humeral defense mechanisms being maximized, thus decreasing infection rates.56,57

One may perform fixation and stabilization following irrigation and debridement.55 There are multiple options for stabilization, ranging from internal fixation to external fixation. Treatment decisions are based on the location and extent of skeletal trauma. External or percutaneous fixation is particularly useful in crush injuries with significant soft tissue trauma. These fixation options do not require incisions that violate the zone of injury.55 One should perform definitive fixation as soon as the soft tissues are stable.55 Basic fracture management principles include delicate soft tissue handling, maintaining wide skin bridges, limited subcutaneous dissection and minimal soft tissue dissection of fracture fragments.55

In Conclusion
Crush injuries of the foot often involve both soft tissue and osseous structures. These injuries are serious and are associated with a significant amount of morbidity.2 Therefore, it is important not to underestimate the serious nature of these injuries. Early recognition and treatment of compartment syndrome is imperative. Performing thorough debridement of all non-viable tissue is essential before initiating early soft tissue coverage. One would pursue skeletal stabilization for fracture management and wound care.
Quick and aggressive treatment of these serious and potentially devastating injuries is essential in order to minimize complications such as ischemic contractures, paralysis, amputations and complex regional pain syndrome.

Dr. Tankersley is a surgical resident within the Division of Foot and Ankle Surgery at the Western Pennsylvania Hospital in Pittsburgh, Pa.

Dr. Mendicino is the Chief of the Division of Foot and Ankle Surgery at the Western Pennsylvania Hospital in Pittsburgh, Pa. He is a Fellow and Past President of the American College of Foot and Ankle Surgeons. Dr. Mendicino is also a Clinical Professor of Surgery at the Western Campus of the Temple University School of Medicine.

Dr. Catanzariti is the Director of Residency Training Programs for the Division of Foot and Ankle Surgery at the Western Pennsylvania Hospital in Pittsburgh, Pa. He is a Fellow of the American College of Foot and Ankle Surgeons and is on the faculty of the Podiatry Institute.

Dr. Grossman is Chief of the Section of Podiatry at the Akron Medical Center in Akron, Ohio. He is a Fellow of the American College of Foot and Ankle Surgeons and is a Clinical Assistant Professor of Podiatry and Orthopedic Surgery at the Northeastern Ohio University’s College of Medicine.


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