Management of Complex Open FractureIn WE

Pr ttaM ing

Te o theex wouex hadtar id; 6fra jointan derw1 r r usCli for asta angeme od, fpla ht bco reewh he mfor iogrthe nkylTh esultcomprehensive management with external fixation. (The Journal of Foot & Ankle Surgery 45(5):308315,2006)

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30y words: midfoot, open fractures, external fixator, crush

rush injuries to the foot are categorized as seriousuries and potentially can lead to amputation. A complexmbination of soft tissue and bony injury may occur withltiple fractures of the tarsal and metatarsal bones, result-in an unstable foot. Initial management includes wound

bridement, anatomic realignment of the foot, stabilizationthe fractures, and soft tissue coverage (1, 2). Early

atomic reduction of all fractures and dislocations withble fixation can minimize long-term morbidity and hastenft tissue healing (35).Traditionally, fractures and dislocations have been re-

duced by open or closed methods and maintained by mul-tiple smooth Kirschner wires or screws augmented by plas-ter immobilization (611). However, these methods areassociated with certain limitations such as inadequate fixa-tion, loss of reduction, pin migration, and pin tract infec-tions. Adequate anatomic restoration and maintenance ofstability in the severely injured foot are often difficult withwires and screws alone. In addition, open reduction andfixation can further devitalize the soft tissues. Moreover,such injuries often require multiple procedures to achievesoft tissue healing.

Despite a comprehensive treatment protocol for patientswith crush injuries to the foot, functional results are notuniformly good (5, 12). Unfortunately, injury classificationschemes do not appear to be helpful in prognosticatingclinical outcomes. Stabilization procedures intended to sal-vage the foot and improve function carry a high rate ofinfection and soft tissue complications, resulting in highamputation rates and persistent pain. Therefore, it has beenrecommended that a decision for amputation be consideredearly during treatment (13).

The management of severe injuries to the foot with ex-ternal fixation is minimally invasive, thereby reducing fur-

Address correspondence to: Prakash Chandran, Specialist Registrar, 15,sswell Close, Callands, Warrington, North Cheshire, WA5 9UA,ited Kingdom. E-mail: prachandran@yahoo.co.uk.1Specialist Registrar, Scarborough General Hospital, Scarborough,st Yorkshire, United Kingdom.2Orthopaedic Surgeon, Bradford, West Yorkshire, United Kingdom.3Associate Professor, Department of Orthopaedics, PGIMER, Chandi-h, India.4Professor in Orthopaedics, Department of Orthopaedics, PGIMER,andigarh, India.Copyright 2006 by the American College of Foot and Ankle Surgeons1067-2516/06/4505-0001$32.00/0doi:10.1053/j.jfas.2006.06.002

8 THE JOURNAL OF FOOT & ANKLE SURGERYjuries of the Midfootxternal Fixation

akash Chandran, MS, AFRCS,1 Ravindra Puandeep Singh Dhillon, MS,3 and Shivender S

n patients (11 feet) with severe, high-velocity, open injuries tternal fixation. The mean patient age was 38 years. Fivetensive degloving of the foot extending into the lower leg. Allsal and metatarsal bones: 9 patients had a fractured cuboctured cuneiform; and all had metatarsal fractures. Lisfrancd intertarsal dislocations were seen in 3 cases. Six patients unequired a myocutaneous flap. The average duration of fixatonically, patients were evaluated 1 year after fixator removalnd on tiptoe, presence of a limp, deformity of an arch, and rtatarsophalangeal joints. Each parameter was graded as gontigrade feet, with 2 patients who experienced pain on weigmfortably on tiptoe, and 2 who limped because of pain. Thereas 4 had cavus deformity. All demonstrated stiffness at tefoot motion, with 5 also having restricted ankle motion. Radtime of follow-up; 4 were malunited, with 1 demonstrating a

ese results suggest that crush injuries to the midfoot often rith

swamaiah, MS,2

h Gill, MS4

midfoot were treated with uniplanarnds measured 10 cm, and 3 hadgrossly comminuted fractures of thehad a fractured navicular; 7 had adislocations were present in 7 feet,ent split-thickness skin grafting, ande was 9 weeks (range, 615 weeks).ny residual pain in the foot, ability toof motion at the ankle, subtalar, andair, or poor. All patients had sensateearing, 5 who had difficulty standingpatients exhibited flatfoot deformity,idfoot and restriction of subtalar andaphically, all fractures were healed atosis across the tarsometatarsal joint.in persistent morbidity despite early

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ou

stephpowe

ex

an

idelat

an

ideredtiopowithefix

an

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ofplathrve

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TABLE 1 Clinical parameters and observations

Parameters Good Fair Poor

NoStaNoGaNoDeNoRaNo

ASTr devascularization (5), and helps maintain alignment) and stability (1517). Unobstructed access for soft

sue management and early joint motion (1, 17) are alsotinct advantages. External fixation can be combined withernal fixation to obtain additional stability. When usedth a dynamic device, minor postoperative corrections cano be achieved. The purpose of this study is to present thenical and functional outcomes of 10 patients treated withniplanar external fixator for midfoot crush injuries.

tients and Methods

Ten patients (11 feet) who presented to the emergencypartment with severe midfoot injuries were included in

study. All patients were seen by one of the authors atsentation; patients with complex midfoot injuries werentified and recruited. A complex injury was defined as anen, high-velocity injury to the midfoot, with unstablectures or fracture dislocations that involved more than 1el, were severely comminuted, and were associated with

tensive soft tissue damage. Isolated fractures of the cal-neus, talus, and simple closed fractures of the remainingsal, metatarsal, or phalangeal bones were excluded froms study.After an initial general assessment and resuscitation, de-ls were collected regarding the type and mechanism ofury to the foot. A complete clinical evaluation of thetient was performed with special attention to the foot.sessment included the condition of the skin, the extent of

soft tissue injury, contamination, bony injury, and aurovascular evaluation of the foot. The wound was copi-sly irrigated with saline solution and covered with arile dressing. All patients were checked for tetanus pro-ylaxis history and received antibiotic coverage. Antero-sterior (AP), lateral, and oblique radiographs of the footre obtained to identify the bony injury, type of fracture,tent of comminution, and displacement and evidence of

Residual Pain None or Trivial

of feet (11) 9nding tiptoe (stability) Ableof feet (11) 6

it (limp) Normalof patients (9) 7

formity (Cavus/Flat feet) Noneof feet (11) 4

nge of movement Full rangeof feet (11)nkle 6ubtalar joint and midfoot 5oes 0

VOLUMEy subluxation or dislocation. The pattern of injury wasntified depending on involvement of the medial and/oreral columns.At the time of surgery, the wound was adequately debridedd irrigated. Fractures, dislocations, and subluxations werentified and reduced. All fractures and dislocations wereuced by either direct or indirect manipulation. Open reduc-n of intraarticular fractures was performed wheneverssible to achieve anatomic reduction. Initially, Kirschnerres were used to stabilize the fractures/dislocations, andfoot was held to length by an assistant while the external

ator was applied.The external fixator was constructed with Kirschner wiresd connecting rods. The connecting rod was threaded andd clamps for attachment to the Kirschner wires. Using thisvice, compression or distraction could be achieved byating the threaded rod. The frame of the external fixators built by first passing 2 Kirschner wires in the safe zonethe calcaneus (18) from medial to lateral in the transversene. Two pairs of Kirschner wires were then passedough the metatarsals distal to the fracture in the trans-rse plane; 1 pair of wires was introduced from the medialect through the first and second metatarsals, while theond pair was passed from the lateral aspect through therth and fifth metatarsals. The proximal and distal sets of

rschner wires (calcaneus and medial metatarsals, calca-us and lateral metatarsals, respectively) were intercon-cted with connecting rods on both sides of the foot. Whenly 1 column was injured, unilateral Kirschner wires withingle connecting rod were used. In patients with gross

mminution, in whom open manipulation and fixationre not possible, the reduction was achieved along thenciples of ligamentotaxis. In such cases, the external fix-r frame was initially applied, reduction was subsequentlyieved by distraction applied to the fracture site, and directssure was also applied, if necessary, to achieve satisfactoryuction. During surgery, attempts were made to reduce all

Mild to Moderate Pain Severe Pain

2 0Difficult Unable

5 0Limp Unable to weight bear

2 0Mild Severe

7 0Some restriction No movements

3 22 47 4

NUMBER 5, SEPTEMBER/OCTOBER 2006 309Kine

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TABLE 2 Patient Summary with Outcome

CaseNu

Age Side Wound Contamination Fractures Dislocations Duration of

rate

re

re

rate

rate

rate

al

Ablate

31raarticular fractures to less than 2-mm displacementng the joint surface.Radiographs were taken intraoperatively to check forcuracy of reduction according to the following radio-phic criteria: 1) congruity of the midtarsal and tarsometa-sal joints on AP, lateral, and oblique views; 2) continuitytween the medial aspect of second metatarsal with thedial aspect of the second cuneiform (Lisfranc joint); andcontinuity between the medial aspect of the fourth meta-sal with the medial aspect of the cuboid (Lisfranc joint).splacement of less than 2 mm was considered acceptable.All wounds were reevaluated after 48 hours and rede-ded if necessary. Patients with skin and soft tissue lossre treated with split-thickness skin grafting or vascular-d free-tissue transfer. Plaster splints were used in patientsth additional ankle or leg injuries. Patients were allowedtive ankle and metatarsophalangeal joint range-of-motionercises immediately after surgery.Postoperatively, AP, lateral, and oblique radiographs of

mber andSex

Size (cm)

1 26/M R 10 Mode

2 40/M L Degloving Seve

3 55/M R Degloving Seve

4 36/M R 10 Mode

5 35/F L 10 Mode

6 25/M R 10 Mode

7 35/M R 10 Minim

8 30/M L 10 Mode

9 50/M L 10 Seve

10 35/M R Degloving Seve

11 L 10 Seve

breviations: M, male; F, female; R, right; L, left; Cub, cuboid; Navral; PWB, pain on weight bearing; MTP, metatarsophalangeal; Min

0 THE JOURNAL OF FOOT & ANKLE SURGERYfoot were obtained and reassessed with the same criteria.y loss of reduction or incongruence of the joint surfaces noted, and an attempt was made to re-reduce thecture or subluxation during subsequent wound debride-nt.The fixator was kept in place for a minimum of 6 weeksuntil adequate soft tissue healing was achieved. Theme was removed 2 weeks after satisfactory soft tissuealing was obtained. After fixator removal, all patientsre kept nonweight bearing for 3 weeks and then allowedrtial weight bearing with a protective boot and arch sup-rt for an additional 6 weeks. All patients received com-hensive physiotherapy and gait training.

One year after fixator removal, all patients were assessedthe follow-up clinic by one of the authors. Clinical andiographic evaluation was performed using the following

rameters. Residual pain, ability to stand on tiptoe (stabil-), limp, deformity of the arch (assessed with footprintsd differentiated into cavus or flat feet), stiffness (assessed

Fixator(wk)

Cub, Nav,Mt 1, 2, 3

9

Nav, Mt 1, 2,3, 4, 5

Phal 2, 3, 4, 5

Lisfrancdislocation

6

Cub, Nav,Cunie 1,2, 3

Mt 2, 3, 4

Lisfrancdislocation

15

Cub 2, Mt 3,4, 5

PP 1

7

Nav, Cub,Cunie 1,2, 3

Mt 3

MTPdislocation2, 3, 4

7

Nav, Cub,Cunie 1,2, 3

Mt 1, 2, 3, 4,5

Lisfrancdislocation

13

Cub, Cunie 1,2, 3

Mt 5

Lisfrancdislocation

4

Cunie 1, 2Mt 2, 3, 4, 5

9

Cub, Cunie 2,3

Mt 4, 5

Lisfranc andmidtarsaldislocation

13

Cub, Latcunie

Mt 1, 2, 3,4, 5

Lisfranc andmidtarsaldislocation

15

Cub, Nav,Mt 2, 3, 4

PP 1

Lisfrancdislocation

6

icular; Mt, metatarsals; Phal, phalangeal; Cunie, cunieform; Lat,imal; PP, proximal phalanx.theAnwa

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TABLE 2 Patient Summary with Outcome

ResidualP

Arch Suppleness Movements Fracture Joint Congruity

N

Pion

Nion

N

N

Nion

N

P

N

P

Nthe ability to pronate and supinate the foot), and range-motion measurements of the ankle subtalar and metatar-

phalngeal joints were recorded. For each parameter, theults were graded as good, fair, or poor as described inble 1. Radiographically, the foot was also assessed forcture healing, nonunion, malunion, congruity of thents, and any persisting subluxation or dislocation.

sults

Ten patients (11 feet) who sustained an injury to thedfoot were studied. The mean patient age was 38 yearsnge, 2555 years), and 90% were men. All patients hadh-velocity injuries due to road traffic accidents. Theury and treatment profiles for all patients can be found inble 2. Three feet had wounds that measured 2 to 10 cm,ad wounds that measured greater than 10 cm, and 3 had

tensive degloving of the foot extending to the lower leg.

ain DeformityAnkle

il Nil Minimumstiffness

Full

WB Flatfoot Grossly stiff Grossrestrict

il Flatfoot Grossly stiff Minrestrict

il Cavusdeformity

Minimumstiffness

Full

il Cavusdeformity

Minimumstiffness

Full

il Cavusdeformity

Grossly stiff Minrestrict

il Nil Minimumstiffness

Full

WB Nil Minimumstiffness

Full

il Cavusdeformity

Minimumstiffness

Minrestrict

WB Flatfoot Grossly stiff Grossrestrict

il Nil Minimumstiffness

Full

VOLUMEe wounds were severely contaminated, 5 were moder-ly contaminated, and 1 had minimal contamination. Se-re contamination was seen in either degloved wounds orger wounds.One foot had an isolated lateral column injury, and the

aining had involvement of both the medial and laterallumns. All cases had fractures involving 1 or more tarsalnes. Nine patients had fractured the cuboid, 6 had frac-ed the navicular, and 7 had fractured cuneiforms. Alltients had at least 1 or more metatarsals fractured, with 3ving fractured all the metatarsal bones and 3 havingncomitant phalangeal fractures. Seven patients had Lis-nc joint dislocations, and 2 patients had midtarsal dislo-tions with disruption of intercuneiform and naviculocu-iform joints. One patient had a dislocation of the second,rd, and fourth metatarsophalangeal joints.Ten feet required biplanar fixators (on either side of thet) to support both columns, and 1 patient required stabi-

UnionToe

Minrestriction

Reduced,united

Congruent

Grossrestriction

Malunion Congruent

Grossrestriction

Reduced,united

Union acrossLisfranc joint

Minrestriction

Malunion Congruent

Minrestriction

Reduced,united

MildincongruenceLisfranc

Grossrestriction

Malunion Congruent

Minrestriction

Reduced,united

Congruent

Minrestriction

Reduced,united

Congruent

Minrestriction

Reduced,united

Congruent

Grossrestriction

Malunion MildincongruenceLisfranc

Minrestriction

Reduced,united

Congruent

NUMBER 5, SEPTEMBER/OCTOBER 2006 311Fivateve

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31ation of only the lateral column. Eight feet requiredditional Kirschner wires to stabilize the fractures. Eightt required more than 1 wound debridement. Six patientseived split-thickness skin grafting, and 1 required a myo-

taneous graft to obtain coverage. Figure 1 demonstrates aical patient enrolled in this case series.

2 THE JOURNAL OF FOOT & ANKLE SURGERYThe average duration of time the fixator was maintaineds 9 weeks (range, 615 weeks). A longer duration of fixatorplication was required in patients with large and severelyntaminated wounds. Two patients required additional plasterinting for associated injuries to the ankle and leg.Two patients developed pin tract infections, which were

FIGURE 1 (A) AP radiograph of severedual-column crush injury. (B) Obliqueview. (C) Oblique view showinguniplanar bilateral fixator applicationand reduction of all dislocations.Kirschner wires were sued to stabilizethe first and second metatarsal frac-tures. (D) Lateral view with fixator inplace. (E) One-year postoperative APradiograph showing alignment of thefoot. (F) Lateral view showing the de-velopment of a cavus deformity.wa

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TABLE 3 Summary of wound size with outcome

Wound Number of Average Pain Deformity Stiffness

tg

11Denaged by local wound care topical antibiotics. None ofinfections were severe enough to require pin relocation.

e patient developed compartment syndrome of the foott required fasciotomy and skin grafting.At 1-year follow-up, all patients had functional feet, allunds had healed, and all fractures had united. All patientsre able to ambulate with full weight bearing, except 1tient, who was kept partial weight bearing because of ancomitant ipsilateral femur and tibia fracture that requiredltiple surgeries. No patient developed complex regional

in syndrome.Eight patients (9 feet) reported no complaints of paingood outcome), 2 had moderate pain on weight bearingfair outcome), and no patient experienced rest pain. Thepatients who had pain with weight bearing exhibited alunion of midtarsal and metatarsal fractures. A modifi-

tion in their shoe gear helped to reduce their symptoms.Six patients were able to stand on tiptoe comfortablygood outcome), and 5 could stand on tiptoe with difficultyfair outcome). Seven were able to walk comfortablygood outcome), 2 were able to mobilize with some painfair outcome), and 1 patient was still nonweight bearingcause of associated injuries.Seven patients (64%) exhibited some degree of arch defor-ty. Three of these exhibited a flatfoot deformity, 4 had aus deformity, and all were rated as having a fair outcome.

l patients with flatfoot deformity had double-column injuriesociated with Lisfranc joint dislocations and at least 3 meta-sal fractures. In those patients with cavus deformity, 3 hadtained an injury to both the medial and lateral columns andad an isolated lateral-column injury.

In terms of ankle joint range of motion, a poor outcomes observed in 2 patients who demonstrated gross re-iction of ankle motion, and 3 patients had some re-iction in motion (fair outcome), with the remainingtients demonstrating good ankle joint motion. All pa-nts exhibited some stiffness of the subtalar and mid-t joints: 4 patients had gross stiffness (poor outcome)

d 2 patients were considered to have a fair result, withremaining rating a good outcome. Of the patients who

monstrated significant stiffness, 3 exhibited a malunionthe tarsals and metatarsals, with residual abnormal

nfiguration of cuneiforms, cuboid and navicular, and 1tient had spontaneous fusion across the Lisfranc joint.

Size Patients DurationFixator Nil Weigh

Bearin

0 cm 3 8 3 00 cm 5 9 4 0gloving 3 12 1 2

VOLUMEl patients had restricted metatarsophalangeal jointge of motion, with gross restriction seen in 4 patientsor outcome) and moderate restriction seen in the re-ining 7 (fair outcome).

Radiographic assessment at 1 year after fixator removalowed that all fractures had united; 4 patients demon-ated a malunion of metatarsal and tarsal bones. Eight feetmonstrated congruence of all joints, whereas 2 patientsmonstrated minimal incongruence at the Lisfranc joint.ese 2 patients had initially demonstrated severely com-nuted cuneiform and cuboid fractures, and it was difficultclearly assess the joint line in the postoperative images.e developed a malunion across the Lisfranc joint, withny ankylosis between the base of the metatarsals and thepective cuneiforms.It was noted that larger wounds required the fixator to

ain in place for a longer duration and had a greatertential for residual pain with weight bearing (Table 3). Inmmary, 49% demonstrated a good outcome and 14%ed poorly.

scussion

In severe injuries to the foot, the severity and pattern ofury play an important role in determining the outcome.propriate wound management, stabilization, and early

ft tissue coverage all contribute to decreasing the potentialrbidity (6, 7, 10, 19). However, the highly variable injury

tterns make comparative evaluation of a series of thesectures difficult.Incomplete or loss of reduction of the fracture and dislo-tion frequently results in permanent disability in the formchronic pain, persisting deformity, and difficulty with

oe gear (20). Although anatomic reduction and stabiliza-n can improve the outcome (2, 2123) in patients withmplex comminuted fractures, it is often difficult tohieve satisfactory results. The results of the current studypport the premise that achieving satisfactory reductiond maintenance of alignment with early soft tissue cover-e allows early bone healing. However, the incidence ofrmanent morbidity due to stiffness and restricted motionn seldom be controlled. Even with seemingly anatomictoration of normal alignment, many patients fare poorly

Nil Cavus FlatFoot

Minimum Gross

1 2 0 2 13 2 0 5 00 0 3 0 3

NUMBER 5, SEPTEMBER/OCTOBER 2006 313su

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(20). Extensive soft tissue crushing with resultant scarringadds to the stiffness and restricted joint motion (15).

Although ring fixators play an increasing role in treatingsu

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position of the fracture and the shape of the foot, scarringand subsequent contracture can seldom be prevented.

In our series, 49% of cases demonstrated good results and14son

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31ch complex injuries, we observed that adequate stabilitythe foot could be provided with a uniplanar bilateral

ternal fixator (16, 23). These devices are technically sim-r, provide adequate stability, and also allow good accesssoft tissue management (15, 17). External fixators can

bilize major open fracture dislocations, maintain lengththe presence of bone loss or extensive comminution,vent soft tissue contractures, control joint position, andvent further devascularization that may occur with openuction (17). The fixator also allows for further manipu-

ion of the fracture postoperatively to improve the positionrequired.The use of an external fixator eliminates the need for addi-nal plaster immobilization (1, 17) and allows for early mo-ization of surrounding joints. In the current series, all pa-nts demonstrated some restriction in toe motion, and 48%d restriction of ankle motion. The severity of the injury wasrhaps a major factor in determining the final outcome.Up to 21% of crush injuries to the foot result in ampu-ion because of either uncontrollable deep sepsis or mas-e injury (15). Even though most of the injuries in ouries were severe, no patient developed deep sepsis oruired an amputation. Adequate initial management, me-

ulous wound care, and the minimally invasive nature ofternal fixation contributed to our ability to salvage thet.

Pin site infection is known to occur with the use ofternal fixation in up to 37% of cases (15, 24, 25). Twotients in this study developed pin site infections thatolved with wound care and local antibiotics. Higher ratespin tract infection are seen when the pins are placedough large volumes of soft tissue (for example, thigh);relatively limited soft tissue envelope of the foot makestract infection less common.

Chronic pain after crush injuries to the foot can resultm neuroischemia, direct trauma to the peripheral nerves,d intraneural or extraneural fibrosis. Direct trauma to therve may also cause chronic neuritis, which can trigger ampathetically mediated pain syndrome (26). With expe-ious treatment, adequate wound coverage, managementany compartment syndromes, and early aggressive reha-itation, many complications, such as chronic pain syn-mes, can be minimized. No patient in the current series

veloped chronic regional pain syndrome.Nemec et al (1) looked at 39 patients with war injuries of

foot and concluded that the external fixator preventedere contractures and facilitated fracture healing. In ouries, 64% developed an arch deformity of the foot: either

vus or flat feet due to scarring, contracture, and bonygration. Although external fixation may help maintain the

4 THE JOURNAL OF FOOT & ANKLE SURGERY% fared poorly. These results are similar to those of Myer-et al (5), who retrospectively reviewed 58 patients with

sh injuries to the foot at a mean interval of 3.3 years. Theyncluded that 46% of the patients had good functional out-mes, and 25% demonstrated poor results. A significant cor-ation was observed between a good functional outcome andeful adherence to the treatment protocol. However, some

tients fared poorly regardless of treatment. Poor results oc-rred if treatment was not initiated immediately and if softsue coverage was delayed. Brunet et al (27) observed norrelation between the initial fracture type and the treatmentthod used with subsequent function of the foot. They foundcorrelation between the radiographic appearance of the

ury and the patients symptoms.Consideration should be given to the patients bone qual-, age, cognitive ability, psychological tolerance, and com-ance level when deciding on management of these inju-s. With these factors kept in mind, the surgeon should bele to select the patient for whom external fixation willld a superior result (28).

mmary

This case series demonstrates that crush injuries of thet are associated with prolonged morbidity, and initialnagement should be directed toward skeletal stabilization

d early soft tissue coverage. The use of external fixationless invasive, can achieve adequate stability, and provideod access for wound management without compromisingbility. However, arch deformity, stiffness, and restrictionsubtalar, midfoot, and toe joint motion occur despite

propriate early management.

ferences

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8. Sands AK, Grose A. Lisfranc injuries. Injury 35(suppl 2):SB7176,2004.

9. Thompson MC, Mormino MA. Injury to the tarsometatarsal jointcomplex. J Am Acad Orthop Surg 11:260267, 2003.

10. Weber M, Locher S. Reconstruction of the cuboid in compressionfractures: short to midterm results in 12 patients. Foot Ankle Int23:10081013, 2002.

11. Wilson DW. Injuries of the tarso-metatarsal joints. Etiology, classifi-cation and results of treatment. J Bone Joint Surg 54B:677686, 1972.

12. Mawhinney IN, McCoy GF. The crushed foot. J R Coll Surg Edinb40:138139, 1995.

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15. Kenzora JE, Edwards CC, Browner BD, Gamble JG, DeSilva JB.Acute management of major trauma involving the foot and ankle withHoffmann external fixation. Foot Ankle 1:348361, 1981.

16. Beals TC. Applications of ring fixators in complex foot and ankletrauma. Orthop Clin North Am 32:205214, 2001.

17. Seibert FJ, Fankhauser F, Elliott B, Stockenhuber N, Peicha G. Ex-ternal fixation in trauma of the foot and ankle. Clin Podiatr Med Surg20:159180, 2003.

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Management of Complex Open Fracture Injuries of the Midfoot With External FixationPatients and MethodsResultsDiscussionSummaryReferences