Crush injuries of the foot in the industrial setting
January 1st, 2002
Anand Vora, MD and Mark Myerson, MD
Introduction:
Crush injuries to the foot can present difficult management issues. Patients invariably suffer soft tissue and skeletal injury that often require complex reconstruction. Even apparently minor crush injuries can cause major complications and lead to long-term sequelae, which may be more difficult to manage in the injured worker. Care of the skin and soft tissues with emphasis on early debridement and coverage appears to have a positive impact on overall results. A thorough understanding of the pathophysiology of these injuries is important to help the treating surgeon coordinate appropriate treatments.
Crush injuries of the foot may occur by multiple defined mechanisms and in several settings. Crush injuries seem to occur commonly in the industrial setting, where preventive measures may help minimize this risk. In this manuscript, we present our treatment philosophy, and highlight the problems inherent and specific to the industrial setting. Emphasis will be placed more on the soft tissues and the sequelae of crush injuries. While compartment syndromes occur frequently in this setting, we would recommend that the reader refers to previously published material on the subject of compartment syndromes of the foot. (20, 24, 25, 27, 29, 31, 32, 33, 42, 48). Although management of the wound, soft tissue coverage, and skeletal stabilization are of paramount importance, one must not ignore the worker. It is a frustrating situation to everyone involved when the foot has “healed” only to find that the patient is unable to return to work due to chronic pain. It is important to recognize many of these issues when evaluating the injured worker, since the results of treatment in this group of patients are quite different from those sustaining similar injuries in other settings.
The National Safety Council in 1984 reported that 4% of work related injuries involve the foot (34). The results of a survey by the Construction Safety Association of Ontario (CSAO) in 1975 stated that 48.6% of the foot and ankle injuries reviewed occurred in men performing heavy labor (6). Oleske et al. (37) characterized data from an occupational injury/illness surveillance system for private-sector companies in a localized urban area and found that workers with jobs involving extensive manual material handling or vehicular operations were the most often injured. They also described the peak of work-related foot injuries in the summer months. They hypothesized that this may be related to less use of proper protective equipment on the job during the warm summer months. Also, during the summer months many industrial positions have a temporary influx of inexperienced employees that may account for this observation. Fifty-five percent of the accidents reported in a Canadian study occurred to workmen under 30 years of age; 65% of the accidents involved workmen with less than 5 years experience in their occupation (5). Recent statistics from The National Electronic Injury Surveillance System (U.S. Consumer Safety Commission) of crushing foot injuries occurring during 2000 support the findings of the above studies and reports and that of Oleske et al. The report reveals that the highest affected subgroup of patients sustaining crush injuries to the foot were males aged 25-44 and that an estimated 58.4% of crush injuries to the foot occurred in the months of May, June, or July (36). The Bureau of Labor Statistics reports that in 1999 the number of nonfatal occupational injuries and illnesses with days away from work involving foot crushes (except toes) by occupation was greatest in laborers, truck drivers, and freight, stock, and material handlers (2). Laborers averaged 12.2 days away from work as a result of a crush injury to the foot (with or without restricted work activity) (2).
The CSAO demonstrated a drop from 25% to 7.3% of all foot and ankle injuries between 1975 and 1987 (5). This is likely the direct result of preventive measurement enforced during this time to prevent injury to the toes by the use of protective footwear with an adequate steel toecap (figure 2). Metatarsal shields are also available although not commonly utilized in the workplace, reflected by the lack of decline of metatarsal or other forefoot injuries during this time period according to CSAO estimates (5).
Robininson et al. (45) attempted to correlate human factors that could be associated with an increased risk in general work-related injuries. They found that being black, having a high-school education or less, being younger, and being employed for a shorted duration on the present job relative to others at the work site may have a significant association with increased injury.
At our institution we treat approximately 200 patients annually for isolated foot and ankle trauma. Of these, approximately 15% of these patients sustain a crushing type of injury. In a retrospective review of the treatment of crush injuries to the foot by the Myerson et al. (29), 24% of patients (14 of 58) suffered their injury secondary to crushing from industrial equipment, and an additional 22% (13 of 58) were injured by motor, industrial, or railway vehicles rolling over the foot. These injuries are a source of increased morbidity and cause a large economic burden to society. In 1988, approximately 110,000 cases of occupationally related foot and toe injuries occurred in the United States resulting in an estimated $2.5 billion in medical and nonmedical costs (35). These injuries often require prolonged treatment and even successful outcomes often do not allow return to work at the previous level of activity.
Initial evaluation and mechanism of injury:
Initial patient evaluation
As in all musculoskeletal trauma, a thorough history is critical. Particular attention should be focused on the pertinent past medical history with emphasis on diseases such as diabetes, vascular disease, and drug or alcohol abuse. Physical examination should focus attention on the neurovascular status and an appreciation of skin and soft tissue injury including signs of abrasions, contusions, lacerations, or internal soft tissue degloving. The soft tissues may not only be traumatized secondary to the direct injury, but also are potentially further compromised by the secondary effects of hypotension, coagulopathy, and cold injury. Cold injury may be focal, such as frostbite, or generalized, as in hypothermia. Efforts should be undertaken to prevent these secondary injuries with rapid and adequate resuscitation and prevention of heat loss. It is also critical to assess patients for signs of compartment syndrome and to obtain compartment pressure measurements in all patients in whom any suspicion is raised (31). Determination of the mechanism of injury is perhaps the single most important factor, as it helps determine not only the type of injury involved but also the extent of injury, and often has an influence on treatments.
Mechanism of injury
The concept of a crush injury must be broad, and by definition encompasses more than a mere direct blow to the dorsal surface of the foot. The crushing force does not always occur perpendicular to the surface of the foot, as for example with a heavy object falling on the foot, but may be tangential to the foot surface. A crush injury is one which therefore occurs from an extrinsic compressive or shear force of variable magnitude applied to the foot over a variable time period. We have previously classified crush injuries of the foot into three specific categories. These seem to present as a spectrum or continuum of tissue injury specific to the soft tissue envelope of the foot (25, 29). The first type occurs when the foot comes into contact with a crushing object that is broad and heavy, typically for an extended period, and a forklift injury is the prototype (figure 1). This type of injury requires a thorough evaluation for associated compartment syndrome, which occurs commonly. A variant of this type of crushing injury occurs when the compressive force comes into contact with the foot for an extensively long period, squeezing and crushing gradually the plantar tissues, causing a bursting of the soft tissues on the plantar foot surface.
The second type of injury occurs when, in addition to crushing, elements of laceration are present, causing severe mangling of tissues. These injuries are generally on the severe end of the soft tissue injury spectrum and often are associated with open comminuted fractures (figure 2).
The final injury type is a crushing injury associated with a shear, degloving, or avulsion of tissue, as when a tangential force is applied to the surface of the foot. In this injury pattern skeletal trauma may be absent and frequently only soft tissue problems result. Cleavage of the skin from its deeper attachments occurs, with soft tissue flaps that may be based either proximally or distally. These injuries should be treated with soft tissue coverage or closure promptly.
Patients should be given appropriate treatment for open injuries including tetanus prophylaxis when applicable and antibiotic coverage. For standard open injuries, a first-generation cephalosporin is adequate. For contaminated wounds antibiotic coverage should be extended (cephalosporin and an aminoglycoside), and for “barnyard” injuries and those injuries grossly contaminated with dirt, penicillin should be added to cover for possible Clostridium infection. The foot should be placed in a compression bulky dressing to minimize swelling and should be kept elevated if nonoperative treatment or delayed operative management is planned.
Once a thorough examination has been completed, we use a regional ankle anesthetic block for pain relief. While there may be some reticence to use a regional block in the setting of severe injuries, this provides such significant relief to the patient, that we use it for all injury types, including those where compartment syndrome may be suspected, since the latter diagnosis should not be made on findings of pain, but upon elevated compartment pressure (24, 25, 28, 31, 33, 42). The ankle block is performed in standard manner using 20ml of 0.5% bupivacaine without epinephrine, as has been described previously (30). The use of a pneumatic intermittent compression foot pump has been documented as an effective method to reduce edema associated with lower extremity trauma in recent prospective study (50). This has been effective in reducing the acute and chronic posttraumatic swelling associated with a crush foot injury (28, 48). Patients are able to tolerate the use of the pump without difficulty (28, 48, 50) and in our experience pain is effectively managed with the regional ankle anesthetic block or a patient controlled anesthesia device.
The scenario of masked compartment syndrome with the use of an anesthetic and placement of the compression device has not been a clinical concern for us, however it is important to emphasize that all patients who are suspected of having a compartment syndrome must have intra-compartment pressures measured prior to undergoing this intervention (28, 31, 48). The “foot pump” (AV Impulse System, Kendall, Mansfield, MA) delivers an air impulse of up to 200 mmHg to the bladder, which is placed over the plantar arch of the foot; this pressure is maintained for 3 seconds before venting. The rapid delivery of inflation impulses (every 20 sec) to the plantar region of the foot generates a venous pulse having a stroke volume of about 20 ml. This will not only improve venous return, but also seems to enhance arterial inflow. These flow increases result in a higher percentage of the capillary network being open, allowing increase osmotic reabsorbtion of interstitial fluid. This technique is discussed more extensively below and in other previously published material (33).
Zone of injury and debridement:
The most important factor in evaluation of the extent of the soft tissue component of the injury is the zone of injury, which is roughly equivalent to the total amount of damaged tissue (10, 24, 25, 26, 29, 32, 33, 41, 54). The injury to the foot is often far worse than immediately and grossly apparent. There is always an extended area of pathologic involvement of the soft tissue and bone beyond the point of impact on the foot (24, 25, 26, 32). This “zone of injury” concept has significant implications for treatment, because the true extent of the injury is often underestimated. This concept applies to any injury, but it is particularly necessary to appreciate the zone of injury in crush trauma.
It has been well established that early soft tissue coverage is critical for effective salvage of the crushed foot (4, 8, 17, 43, 46, 47). All nonviable tissue must be removed before definitive wound closure or coverage can be performed. It is rarely acceptable to allow the wound to “demarcate” and a delay in debridement of soft tissue injury is generally detrimental to ultimate coverage and foot function (8). This management does not allow for effective early soft tissue coverage. Further, as the result of inadequate debridements there is an ever expanding area of cellular necrosis associated with edema and, finally, increased focal fibrosis and stiffness. The remaining area of necrotic tissue is a source of infection and the margins of the viable tissue are extremely thickened and stiff as a result of tissue loss and fibrosis. Even if the end result allows for successful coverage, some of the long-term problems associated with the secondary fibrosis and stiffness may be prevented with earlier debridement and soft tissue coverage.
There is no substitute for meticulous debridement and pulsatile lavage, which is laboriously continued and repeated until the wound is completely clean. The longer the wait prior to definitive coverage, the greater is the incidence of wound contamination, bacterial colonization, and infection (4, 17, 46, 47). Early coverage provides an overall lower failure rate, decreased infection rate, fewer overall surgical procedures, increased rate of bone union, and decreased hospital stay (8). This is particularly relevant for tissues devoid of adequate coverage such as articular cartilage, cortical bone, and tendon, which do not survive if left exposed. In these scenarios urgent coverage is necessary with the recognition that the potential for infection is increased where the recipient bed is marginal. While treatment of these tissues with moist dressing changes in order to preserve viability is still used, we have found that this is ineffective and can lead to loss of vital tissues that may have been preserved with earlier coverage.
Particular issues in crush injuries deserve attention. Because of the frequent gross contamination of these injuries a thorough debridement is essential. Often pulsatile lavage is not sufficient to remove all the debris and foreign materials from the zone of injury. Thus, manual debridement is often necessary to mechanically remove any additional debris from between the muscle and soft tissue planes. This principle also applies to “road burn” injuries where the dirt and gravel are extremely difficult to remove without extensive mechanical abrasion. Tissues severely involved may require excision, thus leaving large exposed areas of defect that require subsequent skin grafting or coverage. Industrial crush injuries may have gross contamination with oil or greases. Over the counter degreasing agents may be more effective than some of the more abrasive solvents commercially available and multiple applications and repeated pulsatile lavage may be necessary to cleanse the
When debriding the wound, care should be taken to preserve vital structures when possible. Anatomical reference of the sural and superficial peroneal nerves should be recognized during debridement and preservation of these sensory nerves should be exercised when feasible. If any sensory nerves are avulsed, crushed, or otherwise traumatized they should be sharply divided and buried in muscle, or preferably in bone if accessible, in order to prevent the complication of a painful neuroma. Care should be exercised to assure that all tendons are covered, as exposed tendon is not an adequate bed for the placement of skin graft. If the peritenon can be reapproximated over the tendon, then skin grafting is again possible. This is particularly relevant if the anterior or posterior tibial or peroneal tendons are involved, and less so for the intrinsic extensors.
Recognition of the zone of injury and the need for adequate debridement has been expressed. Conventional parameters used to determine tissue viability, including color, bleeding, contractility, and consistency of muscle, serve as a guideline but are inaccurate in their ability to allow for complete differentiation between viable from nonviable tissue. These parameters are mainly useful only to guide debridement where grossly contaminated tissues are obvious. Debridement should be complete in affected areas including bone, tendon, muscle, nerve, and ligation of non-essential vessels. Once adequate debridement has been obtained, primary closure can be an arduous task. Occasionally, however, primary closure can be accomplished with acceptable results. We have found primary closure of crushed foot wounds to be successful in selected cases but prefer alternate methods of coverage when the excellent debridement and a tension free primary approximation cannot be achieved. The advantages of a meshed split-thickness skin graft over that of primary closure include the ability to achieve a tension free biologic barrier with optimal coverage, allowing for the egress of fluid and edema. Bacterial colonization is decreased and pain relief is more readily obtained than with primary closure.
Delineation of the zone of injury and soft tissue coverage
To further accurately delineate the zone of injury and additional areas requiring debridement, we use the technique of split thickness skin excision (STSE) (26, 41, 54) and occasionally we may use fluorescein labeling (20, 21, 22). Fluorescein is a phenolphthalein dye that, in the presence of an intact capillary circulation, fluoresces when exposed to ultraviolet light (20, 21, 22). Flourescein is quite nontoxic in the usual dose range of 10 to 15 mg per kilogram, and we recommend giving 1 ml intravenously as a test dose and the balance over 5 minutes. Flourescence is checked 15 minutes later when the peak extracellular concentration is reached. Fluorescein is rapidly excreted by the kidneys, and the intense yellow discoloration of the skin that occurs usually dissipates after 24 hours. We have frequently used fluorescein testing in the past, and when fluorescence of the soft tissues are present, perfusion of the skin and subcutaneous tissue is adequate.
There are occasions when we still use fluorescein. More commonly however, we find that the use of the split thickness skin graft excision is far more useful to determine viability of tissue and the zone of injury; we now routinely use it to manage crush injuries of the foot associated with shearing and degloving of skin and subcutaneous tissue (26, 54) (figure 3). This technique can delineate avascular tissue margins, predicting areas of deep tissue necrosis, and most importantly, yields skin graft material for early soft tissue coverage of open wounds (39, 40, 41). If there is a skin flap present, STSE commences by suturing the avulsed or sheared flap of skin temporarily down to its original bed. If there is a crush injury which has an intact skin covering, the question often arises as to whether this is going to be viable or not. As discussed above, one should not wait for this to demarcate. One is of course reluctant to harvest a skin graft from the dorsal foot surface if there is no need, yet there are some injuries where it is clear that a full thickness skin loss will occur. The skin is insensate, a whitish discoloration is present, and no capillary refill is present to palpation. For these and those where an avulsion flap is present, a 0.015 in. thick splint-thickness skin graft is then harvested from the potentially nonviable skin flap as well as the adjacent normal skin.
Remember that the purpose of this technique is to delineate the margins of the non-viable skin, as well as yield skin graft for soft tissue coverage. Because the extent of the skin viability is unclear, one can estimate the amount of skin graft that will be required and remove a few more millimeters of potentially “normal” skin on the sides of the crushed skin. Although the contour of the dorsal surface of the foot is irregular, the smaller dermatomes work well enough to harvest the graft. Because the nonviable areas do not bleed, if dermal capillary bleeding is present, the skin is viable. The nonviable skin flap, which is now clearly demarcated by the zone of capillary bleeding, is then excised. The skin that was harvested across both the normal and nonviable skin may be used; it is meshed 1:1.5 and reapplied to the denuded area. This technique is ideally suited to definitive management immediately after injury, because cellular necrosis occurs after 24 to 48 hours, and the epidermal layers would probably no longer be suitable. Although the skin harvested from the nonviable portions of the flap would not be suitable under these circumstances, the STSE technique can nevertheless still be used to delineate the margin of viability, and we have applied the meshed graft as a biologic covering.
The common surgical goal in managing these complex crush injuries of the foot is to provide optimum skin coverage with minimum morbidity. Alternative methods for attaining these goals are clearly available, but they are associated with increasing complexity and morbidity, for example with delayed coverage of the wound. This procedure has the potential for secondary infection of the wound, compounded by the delayed treatment and prolonged hospitalization. Primary wound coverage currently appears to be the treatment of choice in shear avulsion trauma of the extremities. These crush injures are typically associated with lower energy injury for example with motor vehicle accidents in which the foot is run over at lower speeds, shearing the dorsal skin surface off its deeper fascial planes and bone (26). Larger skin flaps are created, often with questionable viability. In these shear injuries, the STSE technique accurately determines the extent of viability of the flap and provides additional skin for immediate coverage. The results of primary wound coverage depend on thorough debridement of the devascularized flap and wound bed, an observation in keeping with current philosophy that the fresh wound is a suitable site for donor tissue. The success of this procedure also depends on careful delineation of the viable and nonviable portions of the flap, particularly when dealing with crushing injuries of the foot involving shearing or avulsion of tissue. In farm injuries or others that are substantially contaminated, immediate coverage may be injudicious. However, do not confuse the treatment of wound closure with sound coverage. Clearly, wound closure with no potential for egress of fluid, may not be acceptable. However, this is not the scenario with application of a meshed split thickness skin graft. There are however situations in which the bed is not suitable for application of split-thickness graft of any nature, e.g., in which bone is exposed or the deeper tissues are nonviable. Such injures may be better suited to application of a free flap.
Other methods of coverage have been utilized with successful results. Traditional treatment by plastic surgeons has included defatting and replacement of the skin as a full-thickness graft (12). Other techniques, such as revascularization of the degloved tissue (9, 53) and free-flap reconstruction (16, 44) have also been advocated. These flaps all share the common theme that immobilization on their vascular bed is required to allow for the graft to “take,” traditionally performed with staples or sutures for fixation. The literature describes three case reports of alternate methods to immobilize the tissues (native skin and/or graft material) of a degloved foot to its bed. The Vacuum-assisted closure device (VAC) has been utilized in these cases with graft takes of 60% (23), 100% (7), and 95% (15). The mode of action of the VAC machine has been well described (52) and has been used successfully enhancing graft takes to 91% in a series of degloving injuries of the legs (foot excluded) (14). The VAC machine is particularly useful in the management of the degloved foot because it provides a constant conforming pressure to the replaced skin, allowing secure contact with the bed and potentially increasing the take of the graft in this difficult area by reducing hematoma and seroma formation (15). The use of this machine may allow for a better reconstruction than would be obtained by skin grafting using conventional dressings or by free-tissue transfer. This raises the possibility of being able to restore a more normal gait than would be possible using a free flap (14) and the technique has the potential advantages off reduced donor-site morbidity, reduced length of hospital stay, reduced cost, and earlier mobilization (15).
Skeletal stabilization:
In contrast to many isolated fractures of the foot, skeletal injury associated with crush injuries often require surgical stabilization to optimize overall outcome (27, 32). Rigid fixation, whether internal or external, allows for improved wound care, due to the elimination of soft tissue micro-motion with movement of the foot and ankle. Although the application of a posterior splint to the limb is an option, we have found that more rigid immobilization, albeit temporary, facilitates wound care, wound healing, and dressing changes (9, 23). While bone union remains important, it is a lower priority than that of the soft tissues, which require more delicate and deliberate treatment to promote healing. Many standard fixation techniques may be utilized to achieve stability, including traditional open reduction and internal fixation devices, however, the use of external fixation is of particular help to restore alignment, while minimizing dissection (33). We prefer to use percutaneously inserted wires and cannulated screws, over those which require more dissection, and a half-pin external fixator, in contrast to transfixation pins.
Muscle balancing:
Following crush injuries claw toe deformities occur commonly. These may be the result of disuse, immobilization of the foot, which leads to rapid atrophy of the intrinsic muscles, or the end result of a missed compartment syndrome. (31, 42). Thus, similar to immobilization in the hand, it is essential to maintain active and passive flexibility distal to the areas immobilized. Supervised physical therapy for passive stretching exercises should be performed daily, with the patient or health care personnel performing these exercises on an hourly basis in between formal therapy sessions. This intense protocol is necessary to maintain muscle integrity (figure 4). If the toes cannot be passively extended, or if a degloving injury of the extensor surface of the foot is present, including the extensor tendons, then some form of outrigger on the toes is necessary to prevent contracture. Rapid fixed flexion contracture of the metatarsophalangeal and interphalangeal joints occur if the extensor tendons are not functioning. While it may be difficult to prevent some of these fixed toe deformities for the reasons noted above, it may be possible to prevent contractures of the foot and ankle with early therapy.
Results of Treatment:
One of the most pervasive problems following crush injuries is the morbidity associated with chronic pain, nerve dysfunction, stiffness of the foot and ankle, as well as pain and sympathetically mediated pain syndromes. Whether these complications are inherent to the injury itself, i.e. the severity of the crushed tissue, or whether the results correlate with the paucity or inadequacy of treatment is not clear. Furthermore, it has been difficult to separate out those individuals who sustained the crush injuries in the work setting from those which occurred elsewhere, since by far the majority of crush type injuries do indeed occur in the industrial setting. In 1972, Omer and Pomerantz (38) reported that 50% of their patients who sustained crushing injuries of the foot required assisted ambulation or had residual pain. Certainly the treatment programs for these injuries have improved since 1972, yet despite these improvements in the treatment of soft-tissue trauma (1, 3, 4, 7, 8, 12, 14, 15, 28, 29, 38, 39, 40, 41, 48, 50, 52, 53, 54) and increased attention to compartment syndromes of the foot (24, 25, 27, 29, 31, 32, 33, 38, 42), morbidity after these injuries remains high. Even with optimal treatment strategies including skeletal stabilization and early soft tissue coverage employed at a tertiary care center, the results of treatment have left many patients with a less than satisfactory recovery (29).
The results of treatment for crush injuries of the foot are difficult to evaluate due to the varied pathogenesis, mechanism, and severity of injury. Myerson et al. (29), quantified the result of treatment according to the type of injury, the presence of a compartment syndrome, the type of treatment initiated, delay between injury and treatment, work-related compensation, the presence of ongoing litigation. By retrospective review, 58 patients with crush injuries between 1986 and 1990 met the inclusion criteria for the study and were available for follow-up. The mean interval for follow-up was three and a half years after the injury. Patients were examined and functional outcome was determined by a foot trauma rating scale. Based on the results of this scoring system, 46% had a good functional outcome, 29% had fair results, and 25% had poor results. There was a significant correlation between a good functional outcome and careful adherence to the treatment protocol; however, some patients faired poorly regardless of treatment. Poor results occurred if treatment was not immediately initiated or if soft tissue coverage was delayed, and particularly in those who experienced severe, mangling-type injuries that necessitated partial foot amputation. The patients who fared the worst were those who subsequently suffered from neuritis or reflex sympathetic dystrophy, or those involved in ongoing workers compensation and litigation. No correlation between mechanism of injury and clinical outcome could be identified. Severe mangling type injuries may result in partial foot amputation and these patients may do well, and their disability may be more a result of functional impairment from partial foot amputation than that from continued pain. In this series, some of the worst results occurred in patients who sustained relatively trivial injuries. Despite the magnitude of forces involved, the presence of compartment syndrome in this series did not lead to a poor result in the majority of patients. This may reflect the early recognition and treatment employed for this condition.
Turchin et al (51) prospectively demonstrated that patients with foot injuries and multiple trauma had a significantly worse outcome that that of patients with multiple trauma without associated foot injuries. The effect of a foot fracture on the general health status of a polytrauma patient was significant and sustained at two-year follow-up. Postinjury evaluation showed that not only were the physical scores affected, but also pain and emotional and social health perception were affected dramatically, more so than the control multiple-trauma patients without foot injuries (51). The authors’ patients were similar to patients with chronic conditions, such as congestive heart failure, ischemic heart diseases, and chronic obstructive pulmonary disease, when using the SF-36 (49). These patients had a variety of foot trauma and not only crush injuries, however, the obvious impact on their lives can be appreciated and it can be expected that the majority of patients with crush foot trauma may suffer from a similar type of effect upon their lives. This may cause an alteration in their ability to return to work and to resume their previous activities. The industrial setting is an area where preventive strategies to limit the risk of injury may be employed. The need for appropriate protective gear and the recognition of those workers who are at higher risk may prevent the occurrence of this devastating injury.
Conclusions:
Over the years what we have found is that patients with relatively minor compressive injuries seem to have a different morbidity, largely due to a constellation of neurological findings, including dysesthesia and hyperesthesias. These are usually multifocal, and often extend far beyond the point of impact of the crushing force. Neuro-ischemia may play a role in the development of chronic pain after crush injuries to the foot, either through direct trauma to the peripheral nerves or by intraneural or extranueral fibrosis. This direct trauma to the nerve may cause chronic neuritis, which then triggers a sympathetically mediated pain syndrome. For the injured worker, these problems seem to be magnified. Early recognition of the extent of injury, the zone of injury, and the need for early soft tissue coverage is essential. With expeditious treatment, wound coverage, treatment of compartment syndromes, and early aggressive rehabilitation, many of the complications of these injuries, including chronic pain syndromes, can be minimized.
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