Review Question - QID 217380

The patient is presenting with a high-energy midfoot injury with all five metatarsals fractured, which is associated with a high incidence of late amputation.

High-energy foot injuries are associated with increased morbidity. Despite successful surgical treatment patients often suffer from short and long-term complications. Late amputations are common and reported to occur in as many as 20% of patients at 1-year. Midfoot and hindfoot injuries with fractures involving the 1st metatarsal or all five metatarsals are associated with an increased risk of late amputation.

Bevevino et al. retrospectively studied a military patient population with lower extremity traumatic injuries to compare an artificial neural network and logistic regression analysis assessing factors associated with subsequent amputation. They reported ASA classification, plantar sensation, fracture treatment before arrival, Gustilo-Anderson classification, Sanders classification, vascular injury, male sex, and dismounted blast mechanism as factors associated with secondary amputation. They concluded the artificial neural network model was 30% more accurate at predicting the need for amputation than traditional regression analysis.

Working et al. performed a retrospective study of 121 operatively treated patients with lower extremity injuries and assessed for factors associated with secondary amputation. They reported fractures involving all five metatarsals (p <0.0001) and fracture of the 1st metatarsal (p = 0.003) were specific fracture patterns associated with late amputation, whereas dislocation or fracture of the distal tibia was not. They concluded high-energy foot injuries are associated with increased morbidity with 20% of patients requiring a secondary amputation at 1 year.

Figure A is an AP radiograph of the right foot with a midfoot fracture-dislocation and fractures of all five metatarsals.

Incorrect answers:
Answer 1: Complex regional pain syndrome is a known complication of high-energy foot trauma, but is not the most common.
Answer 2: Surgical treatment with primary arthrodesis is an option for this patient, but is not the most important issue to discuss regarding long-term prognosis.
Answer 4: Iatrogenic nerve injury is possible with surgical treatment, but is not a pressing issue regarding the long-term prognosis of this patient's injury.
Answer 5: Treatment with open reduction and internal fixation is an option for this patient's injury, but is not the most pressing issue regarding long-term prognosis.