Revascularization of a Crushed Foot and Ankle Mortis

Abstract

Foot crush injury is a difficult problem both from the complexity of the injury pattern standpoint and also the significant clinical and socioeconomic burden that it represents to the patient. Scoring systems exist to predict limb salvage, but the accuracy and implementation of these are varied, and thus clinical judgment must always be employed when attempting limb salvage. This case report describes the first use of a reversed saphenous interposition graft repair of a transected dorsalis pedis in a patient after sustaining crush injuries to the distal lower extremity. The patient was able to undergo partial limb salvage with the use of revascularization and judicious fasciotomies.

Keywords: amputation; crush injury; extremity; extremity trauma; limb salvage; revascularization; trauma; vascular surgery.

Figure 1. Plain film x-ray of the patient's crushed foot obtained in the trauma bay

Plain film x-ray of the patient's right lower extremity. Note the displaced fractures of metatarsals 2-4, displaced right medial malleolar, and tibial metaphysis fractures.

Figure 2. The patient's crushed right lower extremity prior to revascularization

Here we see the patient's right lower extremity prior to revascularization. Significant nonviable tissue debridement and reduction of the open fractures had been completed by the orthopedic consultants.

Figure 3. Patient's right lower extremity after revascularization and compartment release

Shown here is the patient's right lower extremity after revascularization of the dorsalis pedis with a saphenous vein interposition graft and coverage with Integra^TM (Integra LifeSciences, Princeton, NJ). Compartment release was performed in the interdigit space. At this time the tissue was dusky but with Doppler signals in the first interdigit webspace.

Figure 4. Patient's right lower extremity after transmetatarsal amputation

Here is the remnant of the patient's right lower extremity after transmetatarsal amputation. Despite initial loss of all vascular supply distal to the malleolus the patient was able to have partial extremity salvage due. The wound here has maintained coverage with skin substitute due to lack of available viable tissue.