A Guide To Treating Crush Injuries
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 Crush syndrome is a term that describes the manifestations that occur after prolonged crushing pressure on the limbs.11,12 Manifestations are caused by the destruction of muscle tissue and the influx of myoglobin, potassium and phosphorus into the circulation. This can lead to hypovolemic shock, hyperkalemia and if, not treated, acute renal failure.11,13,14 This syndrome is unlikely to occur with an isolated crush injury of the foot, but more likely with an injury to one or both limbs. Historically, the foot has been divided into four compartments: medial, lateral, central and interosseous.15,16 In 1990, Manoli and Weber demonstrated the presence of nine compartments: medial, lateral, superficial, adductor, calcaneus and four interosseous compartments.17 Researchers have suggested the presence of a tenth dorsal compartment containing the extensor digitorum brevis.18 The calcaneal compartment communicates with the deep posterior compartment of the leg, possibly allowing a concurrent compartment syndrome of the foot and leg.19 One should have a high index of suspicion of compartment syndrome when evaluating a crush injury. The most common physical findings you may see with compartment syndrome are relentless pain, loss of palpable pulses, decreased light touch sensation, impaired two-point discrimination, motor deficits and loss of pin prick sensation.4 However, keep in mind that you may not always note these findings with these patients.7 Measuring compartment pressures is the only method for definitively diagnosing a compartment syndrome.4,5,9 Normal compartmental pressure is 8 mmHg or less.9 You would perform a fasciotomy when compartmental pressure exceeds 30 mmHg or when the pressure reaches 10 to 30 mmHg below the diastolic blood pressure.20,21 One should perform a fasciotomy within eight hours of the injury and as soon as one makes the diagnosis.22 A variety of incisional approaches (including plantar, dorsal, plantar and lateral, and medial and dorsal) have been described for performing fasciotomies in the foot.5 Myerson recommends a combined two dorsal and one medial-plantar incision to decompress all nine compartments.9 The two dorsal incisions, located medial to the second metatarsal and lateral to the fourth metatarsal, allow one to release the adductor and interossei compartments.6 The medial plantar incision, located at the plantar medial aspect of the heel, allows access to the medial, lateral, superficial and calcaneal compartments.6 You should leave these incisions open. Manage the wounds with wet to dry dressing changes for five to 10 days. Subsequently, one may perform delayed primary closure or provide coverage with split-thickness skin grafting.17 Key Essentials For Treatment When treating crush injuries, one should begin by obtaining analgesia with a peripheral nerve block of the ankle. This should be done regardless of the magnitude of injury. This includes patients with compartment syndrome. This step does not alter decision making, but does significantly alleviate the patient’s pain.5 Keep in mind that a diagnosis of compartment syndrome is based on elevated compartment pressures and not on pain.4,23-25 Administer local anesthesia about the ankle with 20 cc of 0.5% bupivicaine without epinephrine.26 In order to minimize swelling, proceed to apply a bulky compressive dressing and elevate the foot if surgery is delayed or if you are planning on closed treatment.1 One can use a pneumatic intermittent compression foot pump to reduce swelling when elevation is not sufficient.5 Researchers have shown that using this pump is an effective method of reducing edema after lower extremity trauma.27 More specifically, studies have shown that the modality is successful in reducing edema associated with crush injuries of the foot.25,28 However, if you suspect that patients have compartment syndrome, be sure to measure compartment pressures prior to using the intermittent compression foot pump.1 One should continue to monitor patients for compartment syndrome while using the pump.5 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 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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Kalisman M, Wexler M, Yeschua R: Treatment of extensive avulsions of skin and subcutaneous tissues. J Dermatol Surg Oncol 4: 322-27, 1978. 46. McCraw J, Myers B, Shanklin K: The value of fluoroscein in predicting the vitality of materialized flaps. Plast Reconstr Surg 60: 71-9, 1977. 47. McCraw J, Dibbell D, Carraway J: Clinical definition of independent myocutaneous vascular territories. Plast Reconstr Surg 60: 212-220, 1977. 48. McCraw J, Dibbell D: experimental definition of independent myocutaneous vascular territories. Plast Reconstr Surg 60: 341-52, 1977. 49. Waikakul S: Revascularization of degloving injuries of the limbs. Injury 28: 271-74, 1997. 50. Lai M: Degloved sole and heel. Med J Aust 1: 598-99, 1979. 51. Rautio J: Resurfacing and sensory recovery of the sole. Clin Plast Surg 18: 615-26, 1991. 52. Graf P, Kalpen A, Biemer E: Revascularization versus reconstruction of degloving injuries of the heel: case report. Microsurgery 16: 149-54, 1995. 53. Myerson M: Soft-tissue trauma-acute and chronic management. In: Surgery of the Foot and Ankle, ed. 6, vol. 2, ed by R Mann, M Coughlin, St. Louis, MO, CV Mosby, 1367-1410, 1993. 54. Baumhauer J: Mutilating injuries. In: Myerson M, ed. Disorders of the foot and Ankle. Philadelphia: W.B. Saunders, 1245-64, 2000. 55. Rittman W, Schibli M, Matter P, et al: Open fractures: long term results in 200 consecutive cases. Clin Orthop 138: 132-40, 1979. 56. Wray J: Factors in the pathogenesis of non-union. J Bone Joint Surg Am 47A: 168-73, 1965. 57. Bibbo C, Lin S, Cunningham F: Acute traumatic compartment syndrome of the foot in children. Ped Emerg Care 16: 244-8, 2000. Additional References 58. Papa J, Myerson M: Split-thickness skin excision for crush and degloving injuries of the foot. Perspect Orthop Surg 2: 77-85, 1991. 59. Mubarak S, Owen C: Compartmental syndrome and its relation to the crush syndrome. A spectrum of disease. A review of 11 cases of prolonged limb compression. Clin Orthop 113: 81-89, 1975. 60. Myerson M, Burgess A: The initial evaluation and treatment of the acutely traumatized foot and ankle. In: Jahss M, ed. Disorders of the foot and ankle: medical and surgical management. 2nd edition. Philadelphia: W.B. Saunders; 2209-32, 1991. 61. Grodinsky M: A study of the fascial spaces of the foot and their bearing on infections. Surg Gyn Obst 49: 737-751, 1929. 62. Ziv I, Zeligowski A, Mosheiff R, Lowe J, Wexler M, Segal D: Split-thickness skin excision in severe open fractures. J Bone Joint Surg Am 70: 23-26, 1988.