SLR - January 2020 - Joseph R. Wolf
Reference: Quirine M.J. van der Vliet, Robert C. Lucas, George Velmahos, Roderick M. Houwert, Luke P.H. Leenan, Falco Hietbrink, Marilyn Heng. Foot Fractures in Polytrauma Patients: Injury Characteristics and Timing of Diagnosis. Injury. 2018 June; 49(6)Scientific Literature Review
Reviewed By: Joseph R. Wolf, DPM
Residency Program: Beaumont Wayne Hospital, Wayne, MI
Podiatric Relevance: As Podiatric surgeons we are often consulted to assess injuries of the foot and ankle while a polytrauma patient is in the Emergency department, as a consult for inpatients, or through outpatient referrals presenting weeks after the initial injury. Knowing the frequency of these injuries, promotes greater acuity in diagnosing these conditions can be obtained. Raising awareness is of, particular importance as the secondary survey performed in these patients will often favor more proximal orthopedic injuries and these injuries could be missed.
Methods: A retrospective review was performed at a level one trauma center of patients 18 years of age or greater presenting with an injury severity score of =16 during a 10-year span. Fractures of the foot were categorized into five groups: Calcaneus, Talus, Tarsal bones, Metatarsals and Phalanges. The timing of diagnosis was also evaluated with a delayed diagnosis defined as any diagnosis made after 24 hours, but prior to discharge.
Results: A total of 4394 patients with 4409 admissions for polytrauma were retrospectively reviewed. Of the 4409 polytraumas, foot fractures were present in 221 patients, an incidence of 5 percent. Median age of patients presenting with foot fractures was 43 with 59 percent being male. The most common mechanism of injury was MVC 43 percent followed by falls 25 percent. Of the 221 patients with injuries to the lower extremity, there was a total of 511 fractures with 43 percent of patients presenting with a single fracture, 26 percent with two fractures, 12 percent with three fractures. Metatarsal fractures were the most common with an incidence of 41 percent, 92 percent involving the second through fifth metatarsal, followed by the calcaneus 17 percent and talus 16 percent. Of all the fractures reviewed, 30 percent were classified as having a delayed diagnosis. Fractures of the tarsal bones and phalanges at 38 percent were the most common delayed diagnosis followed by metatarsal fractures at 34 percent.
Conclusions: In the polytrauma setting, injuries to the foot and ankle are frequently overlooked leading to delay in diagnosis and initiation of treatment. In this study the authors concluded that their incidence of 5 percent lower extremity fractures in polytrauma patients was lower than the reported averages of other authors; Ahrberg et al whom found a 7.3 percent incidence or Probst et al with a 13.8 percent incidence. The literature review also exhibited a range of 8.1-38 percent incidence of missed foot and ankle injuries in polytrauma patients which is comparable to the 30 percent reported in this study. This report, along with the other cited articles, indicate the importance of a thorough lower extremity exam in polytrauma patients. The data presented should be used to raise awareness and further engage Podiatric foot and ankle surgeons in the care of polytrauma patients. The consequences of a delay in timely diagnosis or altogether failing to diagnose these fractures can cause patients increased pain/disability, additional admissions/surgery, extended time off work, as well as distrust of the healthcare system and deterioration of the doctor patient relationship. With an incidence of at least one lower extremity fracture per 20 polytrauma patients, Podiatric surgeons should continue and further be engaged in the care of polytrauma patients.