Zwipp H, Dahlen C, Randt T, Gavlik J M
Klinik und Poliklinik für Unfall- und Wiederherstellungschirurgie, Technische Universität Dresden, Germany.
Orthopade. 1997 Dec;26(12):1046-1056. doi: 10.1007/PL00003360.
Following complex foot injuries (incidence up to 52 %) in the multiply-injured patient the ultimate goal remains the same as for all significant foot injuries: the restoration of a painless, stable and plantigrade foot to avoid corrective procedures with moderate results. In the case of a complex trauma of the foot (5 point-score) - e. g. a crush injury - primary amputation in the multiply-injured patient (PTS 3-4) is indicated. Limb salvage (PTS 1-2) depends on the intraoperative aspect during the second look (within 24-48 hours after injury): the debridement has to be radical, the selection of amputation level should be at the most distal point compatible with tissue viability and wound healing. A free tissue transfer should be done early if necessary. Single lesions presenting with a compartment syndrome need an immediate dorsal fasciotomy, in the case of a multiply-injured patient as soon as possible. Open fractures are reduced following radical debridement and temporarily stabilized with K-wires and/or tibiotarsal transfixation with an external fixateur until the definitive ORIF. Dislocation-fractures of the talus type 3 and 4 according to Hawkins' classification need open reduction and internal fixation by screws (titan). Open fractures of the calcaneus are stabilized temporarily by a medial external fixateur after debridement until the definitive treatment. If there is a compartment syndrome an immediate dermatofasciotomy is essential. Like closed, calcanear fractures in multiply-injured patients dislocation-fractures of the Chopart's joint need immediate open reduction only if it is an open fracture or associated with a compartment syndrome. The incidence of a compartment syndrome in the case of dislocation fractures of the Lisfranc's joint is high and therefore a dorsal dermatofasciotomy without delay is critical. Open reduction and internal fixation are achieved either by 1.8 mm K-wires or 3.5 mm cortical screws. To avoid further soft tissue damage a delayed primary closure can be necessary and a temporary tibio-tarsal transfixation is useful. Despite the life-threatening injuries of the multiply-injured patient one must insist on an exact diagnosis of the foot trauma (radiographs in 3 standard projections: exact lateral, dorso-plantar, 45° oblique) if long-term disability due to articular incongruities and complex derangement of the arc geometry of the foot is to be avoided.
在多发伤患者中，复杂足部损伤（发生率高达52%）后的最终目标与所有严重足部损伤相同：恢复无痛、稳定且足底着地的足部，以避免效果一般的矫正手术。对于足部复杂创伤（5分评分），例如挤压伤，多发伤患者（创伤严重度评分3 - 4分）应行一期截肢术。保肢（创伤严重度评分1 - 2分）取决于二次探查术中情况（伤后24 - 48小时内）：清创必须彻底，截肢平面应选择在与组织活力和伤口愈合相容的最远端。如有必要，应尽早进行游离组织移植。出现骨筋膜室综合征的单一损伤需立即行背侧筋膜切开术，对于多发伤患者则应尽快进行。开放性骨折在彻底清创后复位，并用克氏针和/或外固定架进行胫跗关节固定，直至进行确定性切开复位内固定术。根据霍金斯分类法，3型和4型距骨脱位骨折需要切开复位并用螺钉（钛合金）内固定。跟骨开放性骨折在清创后用内侧外固定架临时固定，直至进行确定性治疗。如果存在骨筋膜室综合征，立即行皮肤筋膜切开术至关重要。与闭合性骨折一样，多发伤患者中Chopart关节脱位骨折仅在为开放性骨折或伴有骨筋膜室综合征时才需要立即切开复位。Lisfranc关节脱位骨折发生骨筋膜室综合征的发生率很高，因此立即行背侧皮肤筋膜切开术至关重要。切开复位内固定可采用1.8毫米克氏针或3.5毫米皮质螺钉。为避免进一步软组织损伤，可能需要延迟一期缝合，临时胫跗关节固定会很有用。尽管多发伤患者有危及生命的损伤，但如果要避免因关节不匹配和足部弧形几何结构复杂紊乱导致的长期残疾，必须坚持对足部创伤进行准确诊断（拍摄3个标准投照位的X线片：精确侧位、背跖位、45°斜位）。
