ANSWER TO GRAB BAG CASE #6

Despite the horrific appearance of this patient's injury the foot was felt by our orthopedic surgeons to be entirely salvageable.   There was crush and transection injury to the dorsalis pedis artery but the blood supply was intact via the posterior tibial artery.  He had fair sensation in the toes and was able to flex them!  The multiple mid-foot fractures are severe but repairable using plates and fixators and most of the extensor tendons could be salvaged well enough to allow for a functional foot.  Skin grafting was felt to be a likely future need to repair the extensive soft tissue loss; however, most of the torn and partly avulsed tissue was actually salvaged in the OR.

Emergency medicine's role in this type of injury:

• control bleeding with direct pressure -- do not clamp or crush arteries!

• provide pain control and prophylactic antibiotics

• immunize against tetanus if patient's last booster was more than 5 years ago or unknown

• maintain patient NPO and on IV fluids

• recognize the need for immediate specialist involvement and initiate this while caring for the patient's obvious injury and other medical needs

• evaluate the patient for other trauma that might be ignored given everyone's attention on the apparent and disturbing injury

• Carefully examine wounds and document initial neurovascular status -- be able to accurately describe the injury, fracture types & locations and other findings to your consultant.

• consider other medical needs the patient may have under these circumstances (i.e is he diabetic, hypertensive or at risk of cardiac ischemia / MI given the stress of the injury and anticipated surgery?)

• clear wounds of any visible debris or foreign bodies, irrigate wounds if possible and cover with sterile gauze moistened with sterile saline. 

Submitted by Mark Bogner, M.D.