Combat Foot and Ankle Trauma

Injury to the lower extremity is common in the current conflicts, often severely affecting the foot and ankle. Secondary to continued surgical advances, many lower extremities are able to undergo limb salvage procedures. However, scoring systems still do not reliably predict which patient will be best  served with an amputation or limb salvage. Because of this, limb salvage should be attempted whenever possible, awaiting definitive treatment at a later time. Treatment begins at the time and location of injury with aggressive debridement, with reduction and external fixation of fractures when possible. Serial debridements are often necessary until the traumatic wounds are ready for coverage or closure. Forefoot injuries are treated with varying techniques depending on the location of the injury. Amputation of toes and/or flap coverage is often necessary secondary to tenuous soft tissues.Midfoot injury patterns are complex, possibly requiring arthrodesis, antibiotic spacers, soft tissue coverage, and thin-wire ring external fixation. Hindfoot or calcaneal injuries are often the most difficult to treat, requiring extraordinary efforts to salvage a viable limb. Early reduction of the remaining fragments and percutaneous fixation are often followed by arthrodesis of the subtalar joint. Fractures of the calcaneus requiring free soft tissue coverage frequently lead to amputation. Blast injuries to the lower extremity are severe injuries. They are frequently associated with fractures to multiple levels. Early elective amputation at the level V treatment center is frequently performed. When limb salvage is performed, basic principles must be followed to optimize treatment. (Journal of Surgical Orthopaedic Advances 19(1):70–76, 2010)