Riassunto
Il piede polifratturato presenta interessanti aspetti diagnostici, terapeutici ed evolutivi. Sia in letteratura che nella quotidiana esperienza clinica risulta difficile un inquadramento classifcativo, in quanto il trauma ad alta energia, alla base di questa patologia, crea differenti tipi di lesioni inseribili in due grosse categorie: parti molli e parti ossee.
Nel presente lavoro l’Autore utilizza 48 casi trattati e studiati in maniera prospettica per presentare gli attuali orientamenti terapeutici in materia. Il principio cardine nel trattamento di tale patologia risulta essere un’accurata diagnosi, un trattamento in urgenza che deve prevedere ampio debridement delle lesioni delle parti molli, possibile fonte di contaminazione, utilizzo della vacuumterapia (VAC terapia), dell’ossigenoterapia iperbarica, collaborazione con la chirurgia plastica per innesti cutanei liberi o lembi microvascolari e stabilizzazione ossea con fissazione esterna.
Il second look, sempre necessario a 24 o 48 ore dal trauma, comprende fasciotomie in caso di sindrome compartimentale e decisioni sulla necessità di amputazione.
A seconda del tipo di lesione ossea presente in urgenza, è fondamentale ridurre e stabilizzare le lussazioni; alla guarigione delle parti molli si potrà passare a una ricostruzione delle colonne interrotte, onde dare una stabilità e una morfologia al piede in toto.
Lo scopo finale deve essere la restituzione di un piede stabile al cammino e senza dolore. Gli esiti a distanza dipendono dai principi applicati in urgenza e dall’evoluzione intrinseca delle singole lesioni.
Abstract
The complex foot trauma consists of interesting aspects in diagnosis, treatment and results. Either in literature or in daily clinical experience a complete classification is difficult, because the high energy of the trauma gives very different injuries to bone and soft tissues. In this paper the Author uses 48 cases, treated and studied prospectically, to explain what is meant for crush foot and which are the actual guidelines in the treatment of these severe injuries.
The main purpose before any treatment is a correct diagnosis. The first step is in emergency and consists of a wide debridement of soft tissues injuries; the use of VAC Therapy or Hyperbaric Oxygen Therapy. The presence of a plastic surgeon is useful because, very often, microsurgical flaps are able to prevent infections. The debridement is always followed by external fixation.
During the second look, at 24 or 48 hours from the trauma, the surgeon is able to decide between limb salvage or amputation and to perform fasciotomies in presence of compartment syndromes.
In emergency all the dislocations should be reduced and temporarily fixed and when soft tissues will heal it will be possible to anatomically reduce and fix all the fractures, giving a stable and morphologically correct foot.
Results are strictly linked to the very first treatment and, for single fractures, follow the principles of anatomical reduction and stable fixation, considering also the natural history of the injuries (talar fracture).
Bibliografia
Chandran P, Puttaswamaiah R, Dhillon MS, Gill SS (2008) Management of complex open fracture injuries of the midfoot with external fixation. Foot Ankle Surg 45:308–315
Schildauer TA, Nork SE, Sangeorzan BJ (2003) Temporary bridge plating of the medial column in severe midfoot injuries. J Orthop Trauma 17:513–520
Flaherty JD, Evans DA, Danathy PR (1998) The empty toe phenomenon: a type of closed degloving. Am J Orthop 27:524–525
Kinner B, Tietz S, Muller F et al (2011) Outcome after complex trauma of the foot. J Trauma 70:159–168
Zwipp H (2004) Introduction to foot injuries. Injury 35:S81
Zwipp H, Baumgart F, Cronier P et al (2004) Integral classification of injuries (ICI) to the bones, joints, and ligaments — application to injuries of the foot. Injury 35:S88
Brenner P, Rammelt S, Gavlik JM, Zwipp H (2001) Early soft tissue coverage after complex foot trauma. World J Surg 25:603–609
Rammelt S, Biewener A, Grass R, Zwipp H (2005) Foot injuries in the polytraumatized patient. Unfallchirurg 108:858–865
Tarkin IS, Sop A, Pape HC (2008) High energy foot and ankle trauma: principles for formulating an individualized care plan. Foot Ankle Clin 13:705–723
Mc Guigan FX, Forsberg JA, Andersen RC (2006) Foot and ankle reconstruction after blast injuries. Foot Ankle Clin 11:165–182
Shawen SB, Keeling JJ, Branstetter J et al (2010) The mangled foot and leg: salvage versus amputation. Foot Ankle Clin 15:63–75
Zwipp H, Dahlen C, Randt T, Gavlik JM (1997) Complex trauma of the foot. Orthopade 26:1046–1056
Helfet DL, Howey T, Sanders R, Johansen K (1990) Limb salvage versus amputation. Preliminary results of the Mangled Extremity Severity Score. Clin Orthop Relat Res 256:80–86
Wagner R, Blattert T, Weckbach A (2004) Talar dislocations. Injury 35:S836–S845
Kenwright J, Taylor RG (1970) Major injuries of the talus. J Bone Joint Surg 52:36–48
Vaienti L, Maggi F, Gazzola R, Lanzani E (2011) Therapeutic management of complicated talar extrusion: literature review and case report. J Orthop Traumatol 12:61–64
Klaue K (2004) Chopart fractures. Injury 35:S864–S870
Sands AK, Grose A (2004) Lisfranc injuries. Injury 35:S871–S876
Chiodo CP, Myerson MS (2001) Developments and advances in the diagnosis and treatment of injuries to the tarsometatarsal joint. Orthop Clin North Am 32:11–20
Rammelt S, Heineck J, Zwipp H (2004) Metatarsal fractures. Injury 35:S877–S886
Berry GK, Stevens DG, Kreder HJ et al (2004) Open fractures of the calcaneus: a review of treatment and outcome. J Orthop Trauma 18:202–206