What is the treatment for a crush injury to the foot?

Treatment for Crush Injury of the Foot

Early intensive fluid resuscitation is the cornerstone of treatment for crush injury to the foot, with intravenous fluid administration started as soon as possible to prevent crush syndrome and acute kidney injury. 1

Initial Management

• Begin intravenous fluid resuscitation immediately, with an initial rate of 1000 ml/h to be tapered by at least 50% after 2 hours 1
• Avoid potassium-containing balanced salt fluids (such as Lactated Ringer's solution, Hartmann's solution, and Plasmalyte A) as potassium levels may increase markedly even with intact renal function 1
• Avoid starch-based fluids as they are associated with increased rates of acute kidney injury and bleeding 1
• Insert a bladder catheter to monitor urine output unless there is evidence of urethral injury 1
• Apply cold therapy (crushed or cubed ice with water) to reduce pain, swelling, and edema, limiting application to 20-minute intervals 1

Fluid Management Considerations

• Individualize fluid administration based on:
  • Time since injury: more fluid needed for delayed rescue, but more conservative approach if several days have passed 1
  • Patient demographics: older patients, children, and those with low body mass require less fluid to avoid volume overload 1
  • Volume status: hypotension, bleeding, and third spacing suggest hypovolemia requiring more fluid; reduce fluid with signs of overload, especially in anuria 1

Monitoring and Laboratory Assessment

• Monitor electrolytes, acid-base status, lactate, creatine kinase, blood urea nitrogen, and creatinine levels 1
• Point-of-care devices can provide rapid assessment of critical values like creatinine and potassium 1
• Watch for life-threatening complications such as hyperkalemia, which may require urgent intervention 1

Management of Acute Compartment Syndrome

• Assess for signs of compartment syndrome using the "6 Ps": pain, paresthesia, paresis, pain with stretch, pink color, and (late signs) pulselessness and pallor 1
• Remove any tight-fitting dressings and avoid limb elevation if compartment syndrome is suspected 1
• Consider fasciotomy if:
  • Intracompartmental pressures ≥20 mmHg in hypotensive patients
  • Intracompartmental pressures ≥30 mmHg in uncooperative/unconscious patients
  • Intracompartmental pressures ≥30 mmHg in normotensive patients with positive clinical findings 1
• Note that benefits of fasciotomy decrease, and complications increase, the later it is performed 1

Wound Management

• Clean wounds thoroughly and cover superficial traumatic abrasions with clean occlusive dressings and/or topical antibiotics 1
• Monitor for signs of infection, which is a major cause of morbidity and mortality 2
• Consider conservative treatment of muscle injury when possible, as outcomes are often superior to operative treatment 2

Physical Therapy and Rehabilitation

• Begin supervised exercises focusing on proprioception, strength, coordination, and function as soon as clinically appropriate 3
• Implement functional support (bracing) rather than immobilization to promote faster recovery 3
• Consider continuous cryotherapy or intermittent impulse compression to reduce post-traumatic edema 4

Special Considerations

• In mass casualty situations, fluid may need to be restricted to 3-6 L/day if close monitoring is impossible 1
• Consider the need for renal replacement therapy in cases with life-threatening complications such as acidosis, hyperkalemia, or fluid overload 1
• Amputation should only be performed if lifesaving (e.g., with clearly unsalvageable limb or rapidly spreading, therapy-resistant sepsis) 1

Common Pitfalls

• Failure to recognize crush injury early, missing the narrow time window when intensive fluid resuscitation may prevent acute kidney injury 1
• Inappropriate use of mannitol, which has little extra benefit compared to crystalloid fluid resuscitation alone and is potentially nephrotoxic 1
• Delayed fasciotomy when indicated, which significantly reduces its benefits 1
• Inadequate treatment leading to chronic problems such as decreased range of motion, pain, and joint instability 3