Missed Foot Fractures in Multiple Trauma Patients

SLR - January 2021 - Bridget M. Metzo

Level of Evidence: Level III

Scientific Literature Review

Reviewed By: Bridget M. Metzo, DPM
Residency Program: University Hospital – Newark, NJ

Podiatric Relevance: Missed foot injuries in trauma patients can lead to chronic pathology. Prompt diagnosis and intervention is imperative in order to limit the chance of disability long-term. This study sought to reveal the prevalence of missed foot injuries in trauma patients, and further highlight the need for careful examination of the lower extremity examination during the secondary survey.  

Methods: Data was collected prospectively from the site of the accident until discharge from the hospital using the TraumaRegister DGU. Thirty-four thousand ninety-one-trauma patients were analyzed. Injuries included were ankle fractures with/without soft tissue injuries and ligamentous injuries, calcaneal, talus, metatarsal, toe fractures and amputations. Missed injuries were defined as injuries not diagnosed during the primary or secondary survey, and later diagnosis achieved in the intensive care unit (ICU). 

Results: Of the 34,091 patients evaluated, foot injuries were documented in 2532 cases (7.4 percent). 2,247 sustained a foot fracture (6.6 percent) and 285 sustained ligamentous injuries (0.08 percent). Patients with foot injuries were involved in more high-energy traumas, compared to those without foot injuries. Most common cause of injury in patients with or without foot injures were car accidents. More patients with foot injuries were discharged from the hospital as moderate disabled than those without foot injuries. Time of diagnosis was only documented in (6.5 percent) of patients with foot injuries. 93.5 percent of patients with foot injuries were identified in the emergency room and 6.5 percent were first documented in the ICU. One hundred fifteen amputations, 174 ankle fractures, 1063 calcaneal fractures, 944 metatarsal fractures, 518 talus fractures and 331 toe fractures diagnosed in the emergency room. 8 ankle fracture, 63 calcaneal fractures, 65 metatarsal fractures, 34 talus fractures, and 31 toe fractures were later diagnosed in the ICU. Operative therapy results were not statistically significant. 36.7 percent of patients with foot injuries also had a tibia fracture, and 35 percent had a femur fracture. The majority of missed foot injuries also occurred after car accidents (54 cases or 44.3 percent) or fall >3m (31 cases or 25.4 percent)

Conclusions: Statistically significant results in this study reveal the prevalence of missed foot injuries in trauma patients. The study however failed to reveal the time frame of the eventual diagnosis other than the fact it was discovered in the ICU. Further, the foot traumas diagnosed after discharge was not included. Possible reasons for missed foot trauma may include the level of computed tomography and radiographs following acute trauma not extending to the lower extremity, unless indicated during the secondary survey. The study also recognized the incidence of foot trauma in combination with femur or tibia fractures. Therefore, foot imaging should considered when tibia and femur fractures are present, and in patients with high-energy trauma such as car accidents. This study highlights the importance of a thorough lower extremity exam in the secondary survey.