OUTCOME OF FOOT INJURIES IN MULTIPLY INJURED PATIENTS

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In the past, foot injuries in patients with multiple trauma were thought to be of lesser importance than fractures of long bones. In a more recent prospective study from the authors' institution,59 however, multiple trauma patients with foot injuries were shown to have a poorer functional outcome when compared with matched controls. To address these concerns, this article has two parts. The first part is an overview of general principles in the treatment of foot injuries in the polytrauma patient. The treatment of specific injuries is beyond the scope of this article, but an approach is highlighted that can be remembered when decisions are made regarding these severely injured patients. The second part reviews the findings from the authors' study,59 focusing on functional outcomes of multiple trauma patients with foot injuries.

Section snippets

INITIAL MANAGEMENT OF THE TRAUMA PATIENT

The first phase of trauma management begins with the primary survey, in which life-threatening injuries are identified and treated. The second, or resuscitation, phase occurs simultaneously with the first and is, in essence, the treatment of shock. The third phase includes the secondary survey, which is a head-to-toe physical examination, designed to detect any other non–life-threatening injuries. During this secondary survey, a conscious decision should be made to identify orthopedic injuries,

MISSED OR DELAYED DIAGNOSIS

Despite adherence to appropriate trauma management guidelines, missed injuries can occur in 10% of multiply injured patients.57, 61 Musculoskeletal injuries are the most frequently missed and include spine fractures, carpal injuries, and fractures of the feet.19, 31, 37, 56, 61

Reasons for the delay or missed diagnosis of foot injuries include the need in trauma protocols for life-threatening injuries to take precedence over other injuries. Poor-quality radiographs often are accepted in the rush

HIGH-ENERGY INJURIES

In multiple trauma, foot and ankle injuries are more likely to be direct injuries. Not only is the force transmitted with higher energy, but also it is dissipated directly into the soft tissues, which are traumatized with open wounds, soft tissue loss, neurologic injury, and ischemic insults. In high-energy injuries caused by direct forces, the degree of initial fracture displacement tends to be higher, resulting in increased damage to soft tissues.

The soft tissues not only are traumatized

GENERAL PRINCIPLES

A focused history and physical examination is helpful in the prevention of missed injuries. With regards to a history of vehicular trauma, one must consider the amount and location of damage to the vehicle (e.g. >3 cm of foot plate intrusion)16 and direction of impact and occupant position.45 Associated injury patterns, such as lumbar spine and calcaneal fractures, or lateral compression injury of the pelvis and ipsilateral lower extremity injuries also should be considered.

When evaluating the

GENERAL TREATMENT PRINCIPLES OF FOOT INJURIES

Because there are few prospective studies examining treatment outcomes after foot trauma in multiply injured patients, decisions should be guided by general principles of orthopedic care with several specific concerns regarding trauma in the foot. The basic functional goals include the preservation of a painless, sensate, plantigrade, weight-bearing platform. Gross motion of the foot through the ankle and subtalar joints should be preserved if possible.64

Murray is credited with defining a

VASCULAR COMPROMISE

If neurovascular compromise occurs secondary to displacement of fractures or dislocation, a reduction is required to prevent irreversible damage and should be performed as soon as possible. Pressure necrosis also can result in damage to skin and cartilage from displaced fractures and dislocations and is another indication for an urgent reduction. Displaced fractures of the talar neck are associated with compromise to the talar body blood supply38 and should be reduced urgently and anatomically

COMPARTMENT SYNDROME

Despite the difficulty in diagnosis, particularly in the multiple-trauma patient, compartment syndrome is a well-recognized concern that must be considered with a high index of suspicion and acted on quickly to avoid irreversible ischemia and secondary contracture. The classic signs of compartment syndrome as found in the leg and forearm are not as reliable in the foot, and pain on passive stretch is not a consistent finding.41 Certain injury patterns are associated with increased risk of

GENERAL PRINCIPLES OF FRACTURE TREATMENT

One of the two general treatment principles of foot trauma is the concept of essential and nonessential joints.64 Normal gait depends on motion of essential joints, which include the ankle, subtalar, transverse tarsal (Chopart's), and metatarsolphalangeal joints. Nonessential joints include the intercuneiform and first to third tarsometatarsal joints (Lisfranc). Nonessential joints are required to provide a stable lever arm for propulsion and may be bridged by screws.

The second principle

TIMING OF SURGERY

There is a maximum amount of trauma that a limb can tolerate before skin breakdown. The amount of damage to the soft tissues must be assessed in each case so that surgical trauma does not cause further injury to the swollen extremity. In many cases, surgery may need to be delayed until swelling decreases.

The initial assessment should begin with examination of pulses. The palpation of proximal and distal pulses may be aided by Doppler ultrasound51; triphasic patterns are reassuring, whereas

INVESTIGATIONS

Radiologic investigation begins with standard anteroposterior, lateral, and oblique views of the foot. Ankle series may give a better view of the talus, but a Canale view10 gives a better view of the entire talar neck. This view is taken with the ankle positioned in plantar flexion, the foot in pronation, and the x-ray beam angled at 75° from the horizontal in the anteroposterior plane.10 For calcaneal fractures, an axial or Harris view and Broden's oblique views are useful.30 Stress views may

Talus

Talar neck fractures are worth mentioning in the context of multiple trauma for two reasons: because of their association with high-energy injuries, many of which are open, and because of the risk of avascular necrosis and its long-term sequelae.36, 58 The classification of talar neck fractures has been divided by Hawkins24 into type 1, which is undisplaced; type 2, which is displaced with a subluxation or dislocation of the subtalar joint; and type 3, which has disruption of the subtalar and

LISFRANC

The name of Lisfranc has been given to the joints of the five metatarsal bases and three cuneiform bones and cuboid bone. The keystone to this joint's stability is secondary to the second metatarsal base, which is recessed between the medial and lateral cuneiform bones. Lisfranc's ligament is the large oblique ligament that extends from the medial cuneiform to the base of the second metatarsal. The bone architecture provides a keystone configuration because the bones are wedge shaped, and the

AUTHORS' REVIEW

The purpose of the authors' previous investigation was to assess the functional outcome of multiply injured patients with foot injuries. The goal of orthopedic care is the return of function. Despite this goal, most studies refer to outcomes such as range of motion, strength, complications, and radiographic appearance. A more recent trend has been the use of patient-oriented outcome measures.28 Usually a generic health status survey and a condition-specific survey are used in functional outcome

WHY DO MULTITRAUMA PATIENTS WITH FOOT INJURIES FARE WORSE?

The authors' study was not able to show a difference in outcome between fracture types or methods of treatment, and there were no noted complications from the results of treatment of the foot injuries. This situation may be secondary to a small sample size and may be a limitation of the study; however, the outcome of trauma patients with foot injuries was worse than those without foot injuries for all three of the outcome scales. Even with apparently appropriate diagnosis and treatment,

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    Division of Orthopaedic Surgery, Department of Surgery, Saint Michael's Hospital, University of Toronto, Toronto, Ontario, Canada

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    Copyright © 2001 W. B. Saunders Company. Published by Elsevier Inc. All rights reserved.