Complex Foot and Ankle Injuries

Ground-based blasts have proven common in the current conflicts in Iraq and Afghanistan, producing frequent injuries to the foot and ankle. Both the magnitude and severity of foot and ankle blast injuries are profound. Unlike civilian trauma correlates, battlefield foot and ankle injuries are characterized by an extremely high degree of kinetic energy, producing wide zones of bone and soft tissue injury. Irregularly shaped projectiles create atypical and severely comminuted fractures, often with segmental bone loss. Volumetric muscle and skin loss with damage to critical neurovascular structures further complicate wound management. Additionally, the “outside-in” mechanism of some combat wounds imparts considerable contamination from the projectiles, footwear, and surrounding environment. In addition, blunt force injury secondary to an explosion results as the floor of the vehicle impacts the foot and can cause severe open fracture/dislocation injuries of the forefoot, midfoot, and hindfoot. For these reasons, battlefield foot and ankle trauma is unique and highly variable. Although adherence to the principles outlined in this chapter may serve as a guide to patient management, the orthopedic treatment of foot and ankle blast injuries must proceed in an individually tailored and methodical manner to optimize outcomes.