Acute Soft Tissue Injuries

Puncture Wounds are discussed in Chap 43. Complicated foot infections, gunshot wounds to the foot, and many lawn mower injuries require consultation and/or operative debridement.34 The latter two open injuries require a careful search for associated vascular and tendon injuries, radiographs to document foreign-body presence and bony involvement, consideration of tetanus vaccine and immunoglobulin administration, aggressive wound irrigation, analgesics, and antibiotics in most cases. Do not rely on the presence of fever, abnormal radiographs, or elevated white cell counts and erythrocyte sedimentation rates to exclude the diagnosis of osteomyelitis.25

TURF TOE Forced hyperextension of the the first metatarsophalangeal causes a sprain or tear of the joint capsule. The injury is usually associated with a push-off mechanism from a hard surface. The treatment is conservative, with analgesics and with a supportive shoe to prevent further dorsiflexion.

PLANTAR FASCIA RUPTURE This is a tear in the plantar fascia at the point of insertion on the calcaneum. Patients describe a sudden pop and pain that is usually associated with sudden plantar flexion of the foot. Treatment is nonoperative.

TENDON RUPTURES Acute ruptures of the tendons of the foot are rare and are usually associated with penetrating or lacerating injuries. Extensor and flexor hallucis tendon injuries are repaired primarily. The treatment of other tendon transections is controversial.

CRUSH INJURIES AND COMPARTMENT SYNDROME Injuries caused by crush-type mechanisms without associated skin or bone injuries may appear innocuous. These injuries, however, place the foot at risk for the development of compartment syndrome. Compartment syndrome should be suspected when there is pain out of proportion to the injury. Typically, the foot is tensely swollen, and the pain is not relieved by elevation and is increased by passive dorsiflexion of the big toe. Paresthesias may be present, but pedal pulses and capillary refill are often preserved. If compartment syndrome is suspected, intracompartmental pressures must be measured. There are multiple compartments in the foot. The measure of pressure in these small compartments is technically difficult, and orthopedic consultation may be necessary to exclude this diagnosis. Immediate fasciotomy is required once the diagnosis is confirmed.

DIFFERENTIAL DIAGNOSIS OF SUBACUTE AND CHRONIC FOOT PAIN Patients frequently present to the ED with the complaint of foot pain of varying duration. Although several disorders that cause pain are obvious on inspection, including bunions, ingrown toenails, corns, hammertoes and blisters, other problems require a directed physical examination of the foot. The diagnosis and treatment of these disorders is described in Iable.269-1.

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