576486
research-article2015
FAIXXX10.1177/1071100715576486Foot & Ankle International X(X)Hong et al
Article
Forklift-Related Crush Injuries of the Foot and Ankle
Foot & Ankle International® 2015, Vol. 36(7) 806–811 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1071100715576486 fai.sagepub.com
Choon Chiet Hong, MBBS, MRCSEd1, Nazrul Nashi, MBBS1, Win Sen Kuan, MBBS, MRCSEd (A&E), MCI, FAMS2, Jing Wen Daniel Teh3, and Ken Jin Tan, MBBS, MRCSEd, MMed (Ortho), FRCSEd1
Abstract Background: Forklift-related crush injuries of the foot and ankle are relatively common in cities with shipping and construction industries. There is a paucity of literature on the incidence and sequelae of such injuries. We aimed to describe the incidence, patterns of injuries, sequelae, and morbidity associated with this type of injury. Methods: A retrospective review of all patients with forklift-related crush injuries of the foot and ankle for 4 years was conducted. Patients’ demographics, mechanisms and patterns of injury, fracture type, compartment syndrome, number of reconstructive operations, operative details, length of hospital stay, medical leave, repeat evaluation in emergency room, and complications were recorded and analyzed. Results: There were 113 (2.17%) patients with forklift-related crush injuries out of 5209 patients seen in our institution for injuries of the foot and ankle. Crush injury from the wheels of the forklift truck was the most common mechanism at 71 (62.8%) patients. The forefoot was the most commonly injured region, followed by the midfoot, hindfoot, and ankle, with almost one-third (28.3%) of the patients having multiple injuries to the foot. Nine (8%) had open fractures, while 5 (4.4%) had compartment syndromes. Forty (35.4%) patients required hospitalization, and 35 (87.5%) of those hospitalized required operative intervention. Those who had surgery were more likely to have complications compared with those who did not require operative intervention (16 [45.7%] of 35 patients vs 7 [9%] of 78 patients; P < .05) and more likely to require longer medical leave (mean, 183 vs 30 days, P < .05). Conclusion: Forklift-related crush injuries of the foot and ankle are increasingly common in industrialized cities. The forefoot is commonly affected with involvement of multiple regions. Up to one-third of affected patients required hospitalization and multiple operative interventions resulting in loss of productivity, income, and significant morbidity. The possibility of residual disabilities must be clearly defined to the patients and their employers to manage potential workplace limitations and long-term expectations. Level of Evidence: Level IV, retrospective case series. Keywords: forklift, crush injury of foot and ankle, foot trauma, morbidity Crush injuries of the foot and ankle are regularly seen in hospitals as a result of road traffic accidents or industrial injuries. An increasingly common mechanism of injury is forklift-related crush injuries of the foot and ankle, leading to significant morbidity and sometimes mortality.1,2,3,5,6,11,13 Our institution is situated near a shipping port and an industrial center where the utilization of forklifts is extensive. Over the years, we have noticed a large volume of these injuries presenting to our hospital for treatment. However, there is limited literature reporting on the incidence and sequelae of forklift-related crush injuries of the foot and ankle. Only 3 articles on the subject have been published in orthopaedic journals since the 1990s.1,3,13 We aimed to review and describe our incidence and patterns of injuries, sequelae, and morbidity associated with
these injuries. We hope this review will allow surgeons to better counsel patients with these injuries and help address concerns and expectations, especially regarding long-term morbidity. 1
University Orthopaedic, Hand and Reconstructive Microsurgery Cluster, National University Hospital, Singapore 2 Emergency Medicine Department, National University Hospital, Singapore 3 Yong Loo Lin School of Medicine, National University of Singapore, Singapore Corresponding Author: Choon Chiet Hong, MBBS, MRCSEd, c/o University Orthopaedic, Hand and Reconstructive Microsurgery Cluster, National University Hospital, 1E Kent Ridge Road, Singapore 119228, Singapore. Email: [email protected]
Downloaded from fai.sagepub.com at Bobst Library, New York University on July 2, 2015
807
Hong et al
Number Numb m er of cases aff affecting ffecting individual regions of the fo ffoot ot
Forefo f ot: 74 Forefoot: IIsolated solated d - 46, Multiple - 28
Midfo f ot: 30 Midfoot: Isolated d - 8, Multiple - 22
Hindfo f ot: 28 Hindfoot: IIsolated solated d - 16, Multiple - 12
Ankle: 27 IIsolated solated d - 11, Multiple - 16
Figure 1. Distribution of injuries in the individual regions of the foot and ankle. Isolated: only limited to the region. Multiple: involvement of multiple regions of the foot.
Methods This study was approved by the local institutional review board (IRB). A retrospective review of 5209 patients treated in our institution for injuries of the foot and ankle from January 2009 to December 2012 was performed. These patients were identified using the hospital’s diagnosis and operative code system. Their case notes, electronic records, and X-rays were reviewed. These patients were seen in our institution’s emergency room (ER) for foot and ankle injuries. Out of these patients, we screened for those who sustained forklift crush injuries. All other industrial vehicle-related crush injuries were excluded. All patients were 21 years or older. Pertinent data on patients’ demographics (age and sex), mechanism of injury, pattern of injury, fracture type, presence of compartment syndrome, number of reconstructive operations, operative details, length of hospital stay (LOS), reevaluation in the ER, duration of medical leave, and complications were extracted and analyzed statistically. The mechanisms of injury were classified into 4 categories: (1) crushed by the wheels of a forklift truck, (2) crushed by objects/pallet falling from the forklift truck, (3) struck by forklift truck, or (4) forked by the forklift truck against another object. Patterns of injury were divided into forefoot (phalanges and metatarsals), midfoot (cuboid, navicular, and cuneiforms), hindfoot (talus and calcaneus), and/or ankle injuries. Lisfranc fracture dislocation was grouped into midfoot injury. Fracture type was classified into open or closed fractures. LOS was defined as time from admission to the hospital until the time that the patient was able to be discharged. Reevaluation in the ER and duration of medical leave in days were reviewed. Reevaluation in the ER was defined as an unscheduled repeat visit to the ER after completing their initial visit and treatment. Complications from the crush injuries were recorded and analyzed regardless of whether they were medical or surgical complications. Data entry was performed using a spreadsheet application (Excel 2003; Microsoft Corp, Redmond, WA). Frequency
tables and descriptive statistics (mean, standard deviation, or median where appropriate) were presented for all variables. Categorical variables were presented as proportions, and continuous variables were presented as a mean. The χ2 test was used for comparison between categorical variables, while the Mann-Whitney U test was used for continuous variables. Statistical significance was set at P ≤ .05, and data analysis was performed using SPSS (Version 16; SPSS, Inc, an IBM Company, Chicago, IL).
Results A total of 113 (2.17%) patients who were included in this study after fulfilling the inclusion criteria had forkliftrelated crush injuries of the foot and ankle. The mean age was 37.3 years (range, 21-70 years), and there were 109 (96.5%) men. Sixty-four (56.6%) patients were local residents while the rest were expatriate laborers. The most common mechanism of injury was the following: (1) 71 (62.8%) patients sustained crush injury from the wheels of the forklift truck, (2) 35 (31%) patients were struck by the forklift truck, (3) 4 (3.5%) patients were forked, and (4) 3 (2.7%) had crush injuries from objects falling from the forklift truck. Eighty-one (71.7%) patients had isolated injuries to 1 of the 4 regions of the foot, while 32 (28.3%) had concomitant multiple regional injuries. Referring to individual regions of the foot and ankle, most injuries were as follows: (1) 74 (65.5%) forefoot injuries, (2) 30 (26.5%) midfoot injuries, (3) 28 (24.8%) hindfoot injuries, and (4) 27 (23.9%) ankle injuries (Figure 1). In analyzing the most commonly injured region, the forefoot, we found that 63 (85.1%) of 74 patients with forefoot injuries were crushed by the wheels of the forklift truck (P < .05). In terms of the extent of injuries, 57 (50.4%) of patients had fractures (Figures 2 and 3), while 56 (49.6%) had isolated soft tissue injuries (eg, laceration, open wound, contusion, swelling, hematoma, compartment syndrome). Interestingly, only 3 (5.4%) of the 56 patients with soft tissue injuries had lacerations or degloving injuries without
Downloaded from fai.sagepub.com at Bobst Library, New York University on July 2, 2015
808
Foot & Ankle International 36(7)
Figure 2. Example of forklift crush injury to the foot: Lisfranc fracture dislocation with disruption of the entire tarsometatarsal joint, dorsomedial dislocation of the first metatarsophalangeal joint, second toe proximal phalanx fracture, and displaced short oblique second metatarsal neck fracture.
Figure 3. A combination of forefoot and ankle injuries: third to fifth metatarsal neck fractures, base of fifth metatarsal fracture, and a bimalleolar ankle fracture.
any bony fracture. In patients with fractures, 24 (42.1%) of 57 patients had isolated forefoot fractures involving phalanges and metatarsals followed by 10 (17.5%) of 57 patients with isolated ankle region fractures (Figure 4). Eighteen (31.6%) of 57 patients had multiple regional injuries, of which 13 (72.2%) involved 2 regions, while the remaining
5 (27.8%) patients had all 3 regions involved (Figure 4). Nine (14%) of the 57 patients with bony fractures had open fractures, of which 3 cases were graded as Gustillo 2, 1 case of Gustillo 3A, 4 cases of Gustillo 3B, and 1 case of Gustillo 3C, which was associated with posterior tibial artery disruption. Conversely, 5 (8.8%) of 57 patients with fractures developed compartment syndromes, with 4 having compartment syndrome of the foot, while 1 patient had a compartment syndrome of the leg. Of the 4 patients with compartment syndrome of the foot, 2 had concomitant foreand midfoot fractures; 1 had fractures of the forefoot, hindfoot, and ankle; and the last patient had fractures involving all 3 regions of the foot and ankle. All 5 patients had fasciotomies performed. One patient with fractures of all 3 regions of the foot and ankle had a concomitant open ankle fracture (Gustillo 3A) that was debrided, irrigated, and externally fixated during the fasciotomy surgery. None of the patients with isolated soft tissue injuries developed a compartment syndrome. Three patients required amputations: 1 Syme amputation, 1 transmetatarsal amputation with tibia and fibula shortening, and 1 case of second toe amputation. All 3 patients with amputations had an initial open fracture. The Syme amputation was performed with a dorsalis pedis flap transposition due to a necrotic heel pad and exposed necrotic bone, while the transmetatarsal amputation was performed secondary to extensive crush injury of the forefoot with devascularized plantar skin and tibia-fibula shortening due to a tibia fibula open fracture with a rupture of the posterior tibial artery requiring revascularization using a saphenous vein bypass graft. The second toe amputation was a completion amputation as the toe was already crushed and partially amputated at the level of the distal phalanx. In this cohort, 40 (35.4%) patients required hospitalization, while the rest were given outpatient treatment. Among these 40 patients, 35 (87.5%) required surgical intervention while the remaining 5 patients were admitted for pain control, limb elevation, casting, and ambulatory rehabilitation. For those who required operative management, the mean number of reconstructive operations needed was 3 (range, 1-13). Twelve of 35 patients required 3 or more operations to reconstruct and salvage their limbs. The median length of hospital stay was 6 days (range, 1-93 days), while the median duration of medical leave taken by the patients was 35 days (range, 0-421 days). Patients who had operations required longer medical leave compared with nonoperated patients (mean, 183 vs 30 days, P < .05). Nineteen (16.8%) patients revisited the ER after their initial visit and treatment. Only 5 of the 19 who revisited the ER had operative intervention, while the rest were treated conservatively initially (P > .05). No new findings were missed in those patients who revisited the ER. There were 23 (20.4%) patients with postinjury complications such as wound infection, cellulitis, nonunion, chronic pain/stiffness, residual
Downloaded from fai.sagepub.com at Bobst Library, New York University on July 2, 2015
809
Hong et al
Bony injuries n = 57 Isolated
Mul ple
Forefoot
Midfoot
Hindfoot
Ankle
2 regions
3 regions
n = 24
n=3
n=2
n = 10
n = 13
n=5
Medial cuneiform fracture, n=1
Talus fracture, n=1
Metatarsal (MT) fractures, n=11 - 5th MT neck ,n=2 - 5th MT base, n=2 - 3rd MT base, n=1 - 2nd MT base, n=2 - 2/3/5 MT base, n=1 - 3/4/5 MT base, n=1 - 3/4 MT neck , n=1 - 2/3 MT neck, n=1
Lisfranc, medial cuneiform and cuboid fractures, n=1
Calcaneus fracture, n=1
Navicular and medial cuneiform fractures, n=1
Weber B ankle fractures, n=2 Weber C trimalleolar ankle fracture, n=1 Medial malleolus fractures, n=4 Distal fibula and plafond fracture, n=1 Distal bia fracture, n=1 Distal fibula fracture, n=1
Phalanx (P) fractures, n =13
Lisfranc and 5th toe P3 fractures, n=1 Lisfranc and 2/3 MT base fractures, n=1 Lisfranc, 1st toe MTPJ disloca on, 1/2/3 TMTJ disloca on, 2nd toe MT neck and P1 fractures, n=1 Lisfranc, medial cuneiform and medial malleolus fractures, n=1 Lisfranc, navicular, cuboid and Weber C ankle fractures, n=1 Lisfranc, 1/2/3/4 MT base, medial cuneiform fractures and 2nd toe MTPJ disloca on, n=1 3/4/5 MT neck, 5th MT base and Weber B ankle fractures, n=1
- 1st toe P1, n=1 - 1st toe P2, n=2
2/3 MT body and cuboid fractures, n=1
- 5th toe P1, n=2 - 5th toe P3, n=3
3/4 MT base, 5th MT neck and medial malleolus fractures, n=1
- 4/5 toe P3, n=1 - 1st toe P2, n=1
All 5 IPJ fracture disloca on and distal bia fibula fractures, n=1
- 2nd toe P3, n=2 2/3/4 MT neck and 5th toe P3 fractures, n=1
Lisfranc, navicular, all cuneiform, cuboid, talus, calcaneus and Weber C ankle fractures, n=1 2/3/4/5 MT base, Lisfranc, navicular, cuneiform and Weber B ankle fractures, n=1 1/5 toe P1, 2/3/4/5 MT head, 3/4/5 MT base, navicular, cuneiform, cuboid, talus and calcaneus fractures, n=1 5th MT neck, calcaneus and Weber B trimalleolar ankle fractures, n=1 4th MT base, cuboid and calcaneus fractures, n=1
5th toe P1, 3/5 MT base, and distal biafractures, n=1 5th MT base, talus and calcaneus fractures, n=1 3/4 MT base, cuboid fractures, n=1
Figure 4. Distribution of types of foot and ankle fractures after forklift crush injury. IPJ, interphalangeal joint; MT, metatarsal; MTPJ, metatarsophalangeal joint; P, phalanx; TMTJ, tarsometatarsal joint.
swelling, prominent implant requiring removal, complex regional pain syndrome (CRPS), bulky flap requiring liposuction, and equinus deformity (Table 1). We found that patients who underwent operative interventions were more likely to have complications compared with those who did not require operative intervention (16 [45.7%] of 35 patients vs 7 [9%] of 78 patients; P < .05).
Discussion A forklift truck is a highly powered industrial truck that is used to lift and transport materials for a short distance. It is also used to load, unload, and stack goods in storage facilities or distribution centers. It operates within a confined workspace often in close proximity to adjacent workers and
Downloaded from fai.sagepub.com at Bobst Library, New York University on July 2, 2015
810
Foot & Ankle International 36(7)
Table 1. Postinjury Complications (n = 113). Complication
No. (%) a
Total postinjury complications Wound infection/cellulitis Nonunion Prominent implant requiring removal Chronic pain/stiffness Residual swelling CRPS Bulky flap requiring liposuction Equinus deformity
23 (20.4) 6 (5.3) 3 (2.7) 3 (2.7) 16 (14.2) 10 (8.9) 2 (1.8) 1 (0.9) 1 (0.9)
CRPS, complex regional pain syndrome. a Percentage is the estimated risk of developing at least 1 local postinjury complication and is based on the number of patients and not the number of complications; it is calculated by dividing the number of patients experiencing at least 1 local complication by the total number of patients (N = %) in the study population. If a patient experienced multiple complications under any complication class, the patient was counted only once.
can cause serious and sometimes fatal industrial injuries. Being close to a shipping port and an industrial center, our hospital sees a significant number of forklift-related crush injuries of the foot and ankle. Despite being a relatively common entity, we were surprised to find only 3 articles on forklift-related injuries in orthopaedic journals published in the 1990s with no recent literature reporting on these injuries.1,3,13 Hence, we aimed to review and describe the incidence and patterns of injuries with the sequelae and morbidity associated with these injuries. In our study, we found that the forefoot was the most commonly injured region, followed by the midfoot, hindfoot, and ankle. In addition, almost one-third (28.3%) of the patients had multiple injuries to the foot, with up to 85% having their forefoot crushed by the wheels of the forklift truck. Looking at fractures alone, isolated forefoot fractures constitute up to 42.1% followed by 31.6% for fractures involving multiple regions. In view of the prevalence of such crush injuries, it is important to search for potential strategies to protect the foot, especially in the forefoot region. Kwon et al7 used a custom-designed rig with a load of 150 pounds to crush the cadaveric forefoot from a height of 3 feet. They found that the cadaveric forefoot without a steel toecap boot had statistically significant damage with an average of 8.2 fractured bones per foot, while the cadaveric forefoot with a steel toecap boot averaged 3.6 fractured bones per foot. They concluded that safety boots with steel toecaps can provide additional protection in crush injuries to the foot by limiting the number and severity of metatarsal and proximal phalanx fractures. Unfortunately, steel toecap shoes do not fully protect the forefoot from injury. A forklift truck can weight from 2800 pounds to 45 tons. Therefore, a crush injury from the wheels of the forklift truck can cause even more damage to the bones and soft tissue envelope of
the foot than the study by Kwon et al indicates. Nonetheless, a safety boot should always be worn as it can protect the integrity of the soft tissue, and the steel toecap has been shown to be successful in limiting the number and severity of fractures. We also concur with Kwon and colleagues’ recommendation that a metatarsal guard may be helpful if incorporated into the safety boot. Previous studies have shown that approximately 4.4% of all occupational-related injuries involving the foot and toes were associated with losses in wages, productivity, significant medical costs, and administrative expenses amounting up to $3 billion in total.10 Myerson et al9 reported in their study on crush injuries of the foot that these patients tend to present with a broad spectrum of injuries resulting in unpredictable outcomes and prolonged morbidity. Thiagarajan et al13 reported that only 27 of 48 (56.3%) patients who were involved in forklift-related injuries were still employed at their final review. Nineteen patients had to change the nature of their job to a less demanding one. Twenty-one patients had significant residual disability preventing them from being gainfully employed. We found that our patients presented with a broad spectrum of injuries ranging from simple isolated soft tissue injuries to multiple foot and ankle fractures with severe tissue loss. The management for these patients ranged from simply rest to requiring multiple operative interventions. Despite the difference in management plans, these patients will ultimately require a significant period of time off from work to recuperate, as shown in our findings (median duration of medical leave is 35 days [range, 0-421 days]). This will ultimately lead to a loss of income and productivity in the workplace. Up to one-third of these patients required hospitalization, and 87.5% of those hospitalized patients required operative intervention. Among those who required surgical intervention, an average of 3 operations (range, 1-13) were required, and these surgical interventions were more likely to result in complications such as stiffness, swelling, and CRPS with usually longer medical leaves. This not only impairs their activities of daily living but also prevents them from returning to significant previous workforce activities. Therefore, information on the management plan, complications of injury, and average duration of hospital leave is important, and patients and their employers should be informed as early as possible to delineate their short- and long-term limitations. This knowledge allows the employer and their insurance companies to timely locate jobs requiring less significant physical exertion. Thakur et al12 reported in 2012 that a crush injury, either in isolation or in combination with injury to the forefoot, results in the highest incidence of foot compartment syndrome. They also reported that combined injuries to the forefoot and midfoot are risk factors for the development of a foot compartment syndrome. Similarly, all 4 cases of foot compartment syndrome in our series of forklift-related
Downloaded from fai.sagepub.com at Bobst Library, New York University on July 2, 2015
811
Hong et al crush injuries involved a combination of forefoot and midfoot fractures. We did not have any foot compartment syndrome cases in those patients with isolated crush injuries without fractures. Nevertheless, a high index of suspicion is necessary for patients who present with a crush injury of the foot and especially if they involve isolated fractures in the forefoot or combined fractures in the foot. An open fracture does not rule out the possibility of foot compartment syndrome, as seen in one of our patients who presented with an open trimalleolar ankle fracture. He developed a foot compartment syndrome from the crush injury with combined forefoot, midfoot, and calcaneal fractures.4,8,12 We propose a careful and serial monitoring of the foot if there is a suspicion of the possible development of a compartment syndrome. This is especially true in patients who present with a crush injury of the foot either in isolation or combined with other fractures in the foot and/or ankle. Measures include removing any restrictive dressings around the foot, prevention of systemic hypotension, and elevation of the limb to the level of the heart. Liberal use of a compartment pressure monitoring device is recommended as rising compartment pressure sometimes precedes the clinical findings.4 The limitations of this study include its retrospective nature of data collection and the lack of patient-based outcome measures. This report is solely descriptive and categorical in nature as we attempt to illustrate the incidence, patterns of injuries, sequelae, and morbidity associated with forklift-related crush injuries of the foot and ankle. Besides that, we were unable to define postinjury complications such as residual swelling and stiffness appropriately as these were subjective complaints, and clinical assessments were documented by the treating physician. There were insufficient data on safety boot usage in the retrospective review, rendering us incapable of analyzing the association of safety boots to patterns of injury. In addition, we were also unable to procure the employment status for assessment of morbidity since most were expatriate laborers and had completed their contractual period. Despite these limitations, we were able to obtain and present the diverse mechanisms and patterns of injuries from forklift-related crush injuries of the foot and ankle with their accompanying disabilities.
Conclusion Forklift-related crush injuries of the foot and ankle are relatively common in cities with shipping and construction industries. The forefoot is commonly affected with
involvement of multiple regions. Up to one-third of affected patients require hospitalization and multiple operative interventions. This can lead to loss of productivity, loss of income, and significant morbidity. The possibility of residual disability must be emphasized to patients and employers to manage their potential short- and long-term limitations. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
References 1. Born CT, Ross SE, Aron B, DeLong WG, Iannacone WM. Patterns of injury and disability caused by forklift trucks. J Trauma. 1996;40(4):636-639. 2. Collins JW, Smith GS, Baker SP, Warner M. Injuries related to forklifts and other powered industrial vehicles in automobile manufacturing. Am J Ind Med. 1999;36(5):513-521. 3. Darcy CM, Lovell ME, Metcalfe JW. Injuries from forklift trucks. Injury. 1995;26(4):285. 4. Dodd A, Le I. Foot compartment syndrome: diagnosis and management. J Am Acad Orthop Surg. 2013;21(11):657-664. 5. Janicak CA, Deal GA. Occupational fatalities involving forklifts. J Trauma. 1999;47(6):1084-1087. 6. Lifschultz BD, Donoghue ER. Deaths due to forklift truck accidents. Forensic Sci Int. 1994;65(2):121-134. 7. Kwon JY, Campbell JT, Myerson MS, Jeng CL. Effect of a steel toe cap on forefoot injury pattern in a cadaveric model. Foot Ankle Int. 2011;32(4):443-447. 8. Matsen FA III. Compartmental syndrome: a unified concept. Clin Orthop Relat Res. 1975;113:8-14. 9. Myerson MS, McGarvey WC, Henderson MR, Hakim J, Morbidity after crush injuries to the foot. J Orthop Trauma. 1994;8(4):343-349. 10. National Safety Council. Injury Facts. Itasca, IL: National Safety Council; 2001. 11. Stout-Wiegand N. Characteristics of work related injuries involving forklift trucks. J Saf Res. 1987;18:179-181. 12. Thakur NA, McDonnell M, Got CJ, Arcand N, Spratt KF, DiGiovanni CW. Injury patterns causing isolated foot compartment syndrome. J Bone Joint Surg Am. 2012;94(11): 1030-1035. 13. Thiagarajan P, Neeta S, Das De S. Forklift related injuries. J Orthop Surg. 1998;6(2):11.
Downloaded from fai.sagepub.com at Bobst Library, New York University on July 2, 2015
research-article2015
FAIXXX10.1177/1071100715576486Foot & Ankle International X(X)Hong et al
Article
Forklift-Related Crush Injuries of the Foot and Ankle
Foot & Ankle International® 2015, Vol. 36(7) 806–811 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1071100715576486 fai.sagepub.com
Choon Chiet Hong, MBBS, MRCSEd1, Nazrul Nashi, MBBS1, Win Sen Kuan, MBBS, MRCSEd (A&E), MCI, FAMS2, Jing Wen Daniel Teh3, and Ken Jin Tan, MBBS, MRCSEd, MMed (Ortho), FRCSEd1
Abstract Background: Forklift-related crush injuries of the foot and ankle are relatively common in cities with shipping and construction industries. There is a paucity of literature on the incidence and sequelae of such injuries. We aimed to describe the incidence, patterns of injuries, sequelae, and morbidity associated with this type of injury. Methods: A retrospective review of all patients with forklift-related crush injuries of the foot and ankle for 4 years was conducted. Patients’ demographics, mechanisms and patterns of injury, fracture type, compartment syndrome, number of reconstructive operations, operative details, length of hospital stay, medical leave, repeat evaluation in emergency room, and complications were recorded and analyzed. Results: There were 113 (2.17%) patients with forklift-related crush injuries out of 5209 patients seen in our institution for injuries of the foot and ankle. Crush injury from the wheels of the forklift truck was the most common mechanism at 71 (62.8%) patients. The forefoot was the most commonly injured region, followed by the midfoot, hindfoot, and ankle, with almost one-third (28.3%) of the patients having multiple injuries to the foot. Nine (8%) had open fractures, while 5 (4.4%) had compartment syndromes. Forty (35.4%) patients required hospitalization, and 35 (87.5%) of those hospitalized required operative intervention. Those who had surgery were more likely to have complications compared with those who did not require operative intervention (16 [45.7%] of 35 patients vs 7 [9%] of 78 patients; P < .05) and more likely to require longer medical leave (mean, 183 vs 30 days, P < .05). Conclusion: Forklift-related crush injuries of the foot and ankle are increasingly common in industrialized cities. The forefoot is commonly affected with involvement of multiple regions. Up to one-third of affected patients required hospitalization and multiple operative interventions resulting in loss of productivity, income, and significant morbidity. The possibility of residual disabilities must be clearly defined to the patients and their employers to manage potential workplace limitations and long-term expectations. Level of Evidence: Level IV, retrospective case series. Keywords: forklift, crush injury of foot and ankle, foot trauma, morbidity Crush injuries of the foot and ankle are regularly seen in hospitals as a result of road traffic accidents or industrial injuries. An increasingly common mechanism of injury is forklift-related crush injuries of the foot and ankle, leading to significant morbidity and sometimes mortality.1,2,3,5,6,11,13 Our institution is situated near a shipping port and an industrial center where the utilization of forklifts is extensive. Over the years, we have noticed a large volume of these injuries presenting to our hospital for treatment. However, there is limited literature reporting on the incidence and sequelae of forklift-related crush injuries of the foot and ankle. Only 3 articles on the subject have been published in orthopaedic journals since the 1990s.1,3,13 We aimed to review and describe our incidence and patterns of injuries, sequelae, and morbidity associated with
these injuries. We hope this review will allow surgeons to better counsel patients with these injuries and help address concerns and expectations, especially regarding long-term morbidity. 1
University Orthopaedic, Hand and Reconstructive Microsurgery Cluster, National University Hospital, Singapore 2 Emergency Medicine Department, National University Hospital, Singapore 3 Yong Loo Lin School of Medicine, National University of Singapore, Singapore Corresponding Author: Choon Chiet Hong, MBBS, MRCSEd, c/o University Orthopaedic, Hand and Reconstructive Microsurgery Cluster, National University Hospital, 1E Kent Ridge Road, Singapore 119228, Singapore. Email: [email protected]
Downloaded from fai.sagepub.com at Bobst Library, New York University on July 2, 2015
807
Hong et al
Number Numb m er of cases aff affecting ffecting individual regions of the fo ffoot ot
Forefo f ot: 74 Forefoot: IIsolated solated d - 46, Multiple - 28
Midfo f ot: 30 Midfoot: Isolated d - 8, Multiple - 22
Hindfo f ot: 28 Hindfoot: IIsolated solated d - 16, Multiple - 12
Ankle: 27 IIsolated solated d - 11, Multiple - 16
Figure 1. Distribution of injuries in the individual regions of the foot and ankle. Isolated: only limited to the region. Multiple: involvement of multiple regions of the foot.
Methods This study was approved by the local institutional review board (IRB). A retrospective review of 5209 patients treated in our institution for injuries of the foot and ankle from January 2009 to December 2012 was performed. These patients were identified using the hospital’s diagnosis and operative code system. Their case notes, electronic records, and X-rays were reviewed. These patients were seen in our institution’s emergency room (ER) for foot and ankle injuries. Out of these patients, we screened for those who sustained forklift crush injuries. All other industrial vehicle-related crush injuries were excluded. All patients were 21 years or older. Pertinent data on patients’ demographics (age and sex), mechanism of injury, pattern of injury, fracture type, presence of compartment syndrome, number of reconstructive operations, operative details, length of hospital stay (LOS), reevaluation in the ER, duration of medical leave, and complications were extracted and analyzed statistically. The mechanisms of injury were classified into 4 categories: (1) crushed by the wheels of a forklift truck, (2) crushed by objects/pallet falling from the forklift truck, (3) struck by forklift truck, or (4) forked by the forklift truck against another object. Patterns of injury were divided into forefoot (phalanges and metatarsals), midfoot (cuboid, navicular, and cuneiforms), hindfoot (talus and calcaneus), and/or ankle injuries. Lisfranc fracture dislocation was grouped into midfoot injury. Fracture type was classified into open or closed fractures. LOS was defined as time from admission to the hospital until the time that the patient was able to be discharged. Reevaluation in the ER and duration of medical leave in days were reviewed. Reevaluation in the ER was defined as an unscheduled repeat visit to the ER after completing their initial visit and treatment. Complications from the crush injuries were recorded and analyzed regardless of whether they were medical or surgical complications. Data entry was performed using a spreadsheet application (Excel 2003; Microsoft Corp, Redmond, WA). Frequency
tables and descriptive statistics (mean, standard deviation, or median where appropriate) were presented for all variables. Categorical variables were presented as proportions, and continuous variables were presented as a mean. The χ2 test was used for comparison between categorical variables, while the Mann-Whitney U test was used for continuous variables. Statistical significance was set at P ≤ .05, and data analysis was performed using SPSS (Version 16; SPSS, Inc, an IBM Company, Chicago, IL).
Results A total of 113 (2.17%) patients who were included in this study after fulfilling the inclusion criteria had forkliftrelated crush injuries of the foot and ankle. The mean age was 37.3 years (range, 21-70 years), and there were 109 (96.5%) men. Sixty-four (56.6%) patients were local residents while the rest were expatriate laborers. The most common mechanism of injury was the following: (1) 71 (62.8%) patients sustained crush injury from the wheels of the forklift truck, (2) 35 (31%) patients were struck by the forklift truck, (3) 4 (3.5%) patients were forked, and (4) 3 (2.7%) had crush injuries from objects falling from the forklift truck. Eighty-one (71.7%) patients had isolated injuries to 1 of the 4 regions of the foot, while 32 (28.3%) had concomitant multiple regional injuries. Referring to individual regions of the foot and ankle, most injuries were as follows: (1) 74 (65.5%) forefoot injuries, (2) 30 (26.5%) midfoot injuries, (3) 28 (24.8%) hindfoot injuries, and (4) 27 (23.9%) ankle injuries (Figure 1). In analyzing the most commonly injured region, the forefoot, we found that 63 (85.1%) of 74 patients with forefoot injuries were crushed by the wheels of the forklift truck (P < .05). In terms of the extent of injuries, 57 (50.4%) of patients had fractures (Figures 2 and 3), while 56 (49.6%) had isolated soft tissue injuries (eg, laceration, open wound, contusion, swelling, hematoma, compartment syndrome). Interestingly, only 3 (5.4%) of the 56 patients with soft tissue injuries had lacerations or degloving injuries without
Downloaded from fai.sagepub.com at Bobst Library, New York University on July 2, 2015
808
Foot & Ankle International 36(7)
Figure 2. Example of forklift crush injury to the foot: Lisfranc fracture dislocation with disruption of the entire tarsometatarsal joint, dorsomedial dislocation of the first metatarsophalangeal joint, second toe proximal phalanx fracture, and displaced short oblique second metatarsal neck fracture.
Figure 3. A combination of forefoot and ankle injuries: third to fifth metatarsal neck fractures, base of fifth metatarsal fracture, and a bimalleolar ankle fracture.
any bony fracture. In patients with fractures, 24 (42.1%) of 57 patients had isolated forefoot fractures involving phalanges and metatarsals followed by 10 (17.5%) of 57 patients with isolated ankle region fractures (Figure 4). Eighteen (31.6%) of 57 patients had multiple regional injuries, of which 13 (72.2%) involved 2 regions, while the remaining
5 (27.8%) patients had all 3 regions involved (Figure 4). Nine (14%) of the 57 patients with bony fractures had open fractures, of which 3 cases were graded as Gustillo 2, 1 case of Gustillo 3A, 4 cases of Gustillo 3B, and 1 case of Gustillo 3C, which was associated with posterior tibial artery disruption. Conversely, 5 (8.8%) of 57 patients with fractures developed compartment syndromes, with 4 having compartment syndrome of the foot, while 1 patient had a compartment syndrome of the leg. Of the 4 patients with compartment syndrome of the foot, 2 had concomitant foreand midfoot fractures; 1 had fractures of the forefoot, hindfoot, and ankle; and the last patient had fractures involving all 3 regions of the foot and ankle. All 5 patients had fasciotomies performed. One patient with fractures of all 3 regions of the foot and ankle had a concomitant open ankle fracture (Gustillo 3A) that was debrided, irrigated, and externally fixated during the fasciotomy surgery. None of the patients with isolated soft tissue injuries developed a compartment syndrome. Three patients required amputations: 1 Syme amputation, 1 transmetatarsal amputation with tibia and fibula shortening, and 1 case of second toe amputation. All 3 patients with amputations had an initial open fracture. The Syme amputation was performed with a dorsalis pedis flap transposition due to a necrotic heel pad and exposed necrotic bone, while the transmetatarsal amputation was performed secondary to extensive crush injury of the forefoot with devascularized plantar skin and tibia-fibula shortening due to a tibia fibula open fracture with a rupture of the posterior tibial artery requiring revascularization using a saphenous vein bypass graft. The second toe amputation was a completion amputation as the toe was already crushed and partially amputated at the level of the distal phalanx. In this cohort, 40 (35.4%) patients required hospitalization, while the rest were given outpatient treatment. Among these 40 patients, 35 (87.5%) required surgical intervention while the remaining 5 patients were admitted for pain control, limb elevation, casting, and ambulatory rehabilitation. For those who required operative management, the mean number of reconstructive operations needed was 3 (range, 1-13). Twelve of 35 patients required 3 or more operations to reconstruct and salvage their limbs. The median length of hospital stay was 6 days (range, 1-93 days), while the median duration of medical leave taken by the patients was 35 days (range, 0-421 days). Patients who had operations required longer medical leave compared with nonoperated patients (mean, 183 vs 30 days, P < .05). Nineteen (16.8%) patients revisited the ER after their initial visit and treatment. Only 5 of the 19 who revisited the ER had operative intervention, while the rest were treated conservatively initially (P > .05). No new findings were missed in those patients who revisited the ER. There were 23 (20.4%) patients with postinjury complications such as wound infection, cellulitis, nonunion, chronic pain/stiffness, residual
Downloaded from fai.sagepub.com at Bobst Library, New York University on July 2, 2015
809
Hong et al
Bony injuries n = 57 Isolated
Mul ple
Forefoot
Midfoot
Hindfoot
Ankle
2 regions
3 regions
n = 24
n=3
n=2
n = 10
n = 13
n=5
Medial cuneiform fracture, n=1
Talus fracture, n=1
Metatarsal (MT) fractures, n=11 - 5th MT neck ,n=2 - 5th MT base, n=2 - 3rd MT base, n=1 - 2nd MT base, n=2 - 2/3/5 MT base, n=1 - 3/4/5 MT base, n=1 - 3/4 MT neck , n=1 - 2/3 MT neck, n=1
Lisfranc, medial cuneiform and cuboid fractures, n=1
Calcaneus fracture, n=1
Navicular and medial cuneiform fractures, n=1
Weber B ankle fractures, n=2 Weber C trimalleolar ankle fracture, n=1 Medial malleolus fractures, n=4 Distal fibula and plafond fracture, n=1 Distal bia fracture, n=1 Distal fibula fracture, n=1
Phalanx (P) fractures, n =13
Lisfranc and 5th toe P3 fractures, n=1 Lisfranc and 2/3 MT base fractures, n=1 Lisfranc, 1st toe MTPJ disloca on, 1/2/3 TMTJ disloca on, 2nd toe MT neck and P1 fractures, n=1 Lisfranc, medial cuneiform and medial malleolus fractures, n=1 Lisfranc, navicular, cuboid and Weber C ankle fractures, n=1 Lisfranc, 1/2/3/4 MT base, medial cuneiform fractures and 2nd toe MTPJ disloca on, n=1 3/4/5 MT neck, 5th MT base and Weber B ankle fractures, n=1
- 1st toe P1, n=1 - 1st toe P2, n=2
2/3 MT body and cuboid fractures, n=1
- 5th toe P1, n=2 - 5th toe P3, n=3
3/4 MT base, 5th MT neck and medial malleolus fractures, n=1
- 4/5 toe P3, n=1 - 1st toe P2, n=1
All 5 IPJ fracture disloca on and distal bia fibula fractures, n=1
- 2nd toe P3, n=2 2/3/4 MT neck and 5th toe P3 fractures, n=1
Lisfranc, navicular, all cuneiform, cuboid, talus, calcaneus and Weber C ankle fractures, n=1 2/3/4/5 MT base, Lisfranc, navicular, cuneiform and Weber B ankle fractures, n=1 1/5 toe P1, 2/3/4/5 MT head, 3/4/5 MT base, navicular, cuneiform, cuboid, talus and calcaneus fractures, n=1 5th MT neck, calcaneus and Weber B trimalleolar ankle fractures, n=1 4th MT base, cuboid and calcaneus fractures, n=1
5th toe P1, 3/5 MT base, and distal biafractures, n=1 5th MT base, talus and calcaneus fractures, n=1 3/4 MT base, cuboid fractures, n=1
Figure 4. Distribution of types of foot and ankle fractures after forklift crush injury. IPJ, interphalangeal joint; MT, metatarsal; MTPJ, metatarsophalangeal joint; P, phalanx; TMTJ, tarsometatarsal joint.
swelling, prominent implant requiring removal, complex regional pain syndrome (CRPS), bulky flap requiring liposuction, and equinus deformity (Table 1). We found that patients who underwent operative interventions were more likely to have complications compared with those who did not require operative intervention (16 [45.7%] of 35 patients vs 7 [9%] of 78 patients; P < .05).
Discussion A forklift truck is a highly powered industrial truck that is used to lift and transport materials for a short distance. It is also used to load, unload, and stack goods in storage facilities or distribution centers. It operates within a confined workspace often in close proximity to adjacent workers and
Downloaded from fai.sagepub.com at Bobst Library, New York University on July 2, 2015
810
Foot & Ankle International 36(7)
Table 1. Postinjury Complications (n = 113). Complication
No. (%) a
Total postinjury complications Wound infection/cellulitis Nonunion Prominent implant requiring removal Chronic pain/stiffness Residual swelling CRPS Bulky flap requiring liposuction Equinus deformity
23 (20.4) 6 (5.3) 3 (2.7) 3 (2.7) 16 (14.2) 10 (8.9) 2 (1.8) 1 (0.9) 1 (0.9)
CRPS, complex regional pain syndrome. a Percentage is the estimated risk of developing at least 1 local postinjury complication and is based on the number of patients and not the number of complications; it is calculated by dividing the number of patients experiencing at least 1 local complication by the total number of patients (N = %) in the study population. If a patient experienced multiple complications under any complication class, the patient was counted only once.
can cause serious and sometimes fatal industrial injuries. Being close to a shipping port and an industrial center, our hospital sees a significant number of forklift-related crush injuries of the foot and ankle. Despite being a relatively common entity, we were surprised to find only 3 articles on forklift-related injuries in orthopaedic journals published in the 1990s with no recent literature reporting on these injuries.1,3,13 Hence, we aimed to review and describe the incidence and patterns of injuries with the sequelae and morbidity associated with these injuries. In our study, we found that the forefoot was the most commonly injured region, followed by the midfoot, hindfoot, and ankle. In addition, almost one-third (28.3%) of the patients had multiple injuries to the foot, with up to 85% having their forefoot crushed by the wheels of the forklift truck. Looking at fractures alone, isolated forefoot fractures constitute up to 42.1% followed by 31.6% for fractures involving multiple regions. In view of the prevalence of such crush injuries, it is important to search for potential strategies to protect the foot, especially in the forefoot region. Kwon et al7 used a custom-designed rig with a load of 150 pounds to crush the cadaveric forefoot from a height of 3 feet. They found that the cadaveric forefoot without a steel toecap boot had statistically significant damage with an average of 8.2 fractured bones per foot, while the cadaveric forefoot with a steel toecap boot averaged 3.6 fractured bones per foot. They concluded that safety boots with steel toecaps can provide additional protection in crush injuries to the foot by limiting the number and severity of metatarsal and proximal phalanx fractures. Unfortunately, steel toecap shoes do not fully protect the forefoot from injury. A forklift truck can weight from 2800 pounds to 45 tons. Therefore, a crush injury from the wheels of the forklift truck can cause even more damage to the bones and soft tissue envelope of
the foot than the study by Kwon et al indicates. Nonetheless, a safety boot should always be worn as it can protect the integrity of the soft tissue, and the steel toecap has been shown to be successful in limiting the number and severity of fractures. We also concur with Kwon and colleagues’ recommendation that a metatarsal guard may be helpful if incorporated into the safety boot. Previous studies have shown that approximately 4.4% of all occupational-related injuries involving the foot and toes were associated with losses in wages, productivity, significant medical costs, and administrative expenses amounting up to $3 billion in total.10 Myerson et al9 reported in their study on crush injuries of the foot that these patients tend to present with a broad spectrum of injuries resulting in unpredictable outcomes and prolonged morbidity. Thiagarajan et al13 reported that only 27 of 48 (56.3%) patients who were involved in forklift-related injuries were still employed at their final review. Nineteen patients had to change the nature of their job to a less demanding one. Twenty-one patients had significant residual disability preventing them from being gainfully employed. We found that our patients presented with a broad spectrum of injuries ranging from simple isolated soft tissue injuries to multiple foot and ankle fractures with severe tissue loss. The management for these patients ranged from simply rest to requiring multiple operative interventions. Despite the difference in management plans, these patients will ultimately require a significant period of time off from work to recuperate, as shown in our findings (median duration of medical leave is 35 days [range, 0-421 days]). This will ultimately lead to a loss of income and productivity in the workplace. Up to one-third of these patients required hospitalization, and 87.5% of those hospitalized patients required operative intervention. Among those who required surgical intervention, an average of 3 operations (range, 1-13) were required, and these surgical interventions were more likely to result in complications such as stiffness, swelling, and CRPS with usually longer medical leaves. This not only impairs their activities of daily living but also prevents them from returning to significant previous workforce activities. Therefore, information on the management plan, complications of injury, and average duration of hospital leave is important, and patients and their employers should be informed as early as possible to delineate their short- and long-term limitations. This knowledge allows the employer and their insurance companies to timely locate jobs requiring less significant physical exertion. Thakur et al12 reported in 2012 that a crush injury, either in isolation or in combination with injury to the forefoot, results in the highest incidence of foot compartment syndrome. They also reported that combined injuries to the forefoot and midfoot are risk factors for the development of a foot compartment syndrome. Similarly, all 4 cases of foot compartment syndrome in our series of forklift-related
Downloaded from fai.sagepub.com at Bobst Library, New York University on July 2, 2015
811
Hong et al crush injuries involved a combination of forefoot and midfoot fractures. We did not have any foot compartment syndrome cases in those patients with isolated crush injuries without fractures. Nevertheless, a high index of suspicion is necessary for patients who present with a crush injury of the foot and especially if they involve isolated fractures in the forefoot or combined fractures in the foot. An open fracture does not rule out the possibility of foot compartment syndrome, as seen in one of our patients who presented with an open trimalleolar ankle fracture. He developed a foot compartment syndrome from the crush injury with combined forefoot, midfoot, and calcaneal fractures.4,8,12 We propose a careful and serial monitoring of the foot if there is a suspicion of the possible development of a compartment syndrome. This is especially true in patients who present with a crush injury of the foot either in isolation or combined with other fractures in the foot and/or ankle. Measures include removing any restrictive dressings around the foot, prevention of systemic hypotension, and elevation of the limb to the level of the heart. Liberal use of a compartment pressure monitoring device is recommended as rising compartment pressure sometimes precedes the clinical findings.4 The limitations of this study include its retrospective nature of data collection and the lack of patient-based outcome measures. This report is solely descriptive and categorical in nature as we attempt to illustrate the incidence, patterns of injuries, sequelae, and morbidity associated with forklift-related crush injuries of the foot and ankle. Besides that, we were unable to define postinjury complications such as residual swelling and stiffness appropriately as these were subjective complaints, and clinical assessments were documented by the treating physician. There were insufficient data on safety boot usage in the retrospective review, rendering us incapable of analyzing the association of safety boots to patterns of injury. In addition, we were also unable to procure the employment status for assessment of morbidity since most were expatriate laborers and had completed their contractual period. Despite these limitations, we were able to obtain and present the diverse mechanisms and patterns of injuries from forklift-related crush injuries of the foot and ankle with their accompanying disabilities.
Conclusion Forklift-related crush injuries of the foot and ankle are relatively common in cities with shipping and construction industries. The forefoot is commonly affected with
involvement of multiple regions. Up to one-third of affected patients require hospitalization and multiple operative interventions. This can lead to loss of productivity, loss of income, and significant morbidity. The possibility of residual disability must be emphasized to patients and employers to manage their potential short- and long-term limitations. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
References 1. Born CT, Ross SE, Aron B, DeLong WG, Iannacone WM. Patterns of injury and disability caused by forklift trucks. J Trauma. 1996;40(4):636-639. 2. Collins JW, Smith GS, Baker SP, Warner M. Injuries related to forklifts and other powered industrial vehicles in automobile manufacturing. Am J Ind Med. 1999;36(5):513-521. 3. Darcy CM, Lovell ME, Metcalfe JW. Injuries from forklift trucks. Injury. 1995;26(4):285. 4. Dodd A, Le I. Foot compartment syndrome: diagnosis and management. J Am Acad Orthop Surg. 2013;21(11):657-664. 5. Janicak CA, Deal GA. Occupational fatalities involving forklifts. J Trauma. 1999;47(6):1084-1087. 6. Lifschultz BD, Donoghue ER. Deaths due to forklift truck accidents. Forensic Sci Int. 1994;65(2):121-134. 7. Kwon JY, Campbell JT, Myerson MS, Jeng CL. Effect of a steel toe cap on forefoot injury pattern in a cadaveric model. Foot Ankle Int. 2011;32(4):443-447. 8. Matsen FA III. Compartmental syndrome: a unified concept. Clin Orthop Relat Res. 1975;113:8-14. 9. Myerson MS, McGarvey WC, Henderson MR, Hakim J, Morbidity after crush injuries to the foot. J Orthop Trauma. 1994;8(4):343-349. 10. National Safety Council. Injury Facts. Itasca, IL: National Safety Council; 2001. 11. Stout-Wiegand N. Characteristics of work related injuries involving forklift trucks. J Saf Res. 1987;18:179-181. 12. Thakur NA, McDonnell M, Got CJ, Arcand N, Spratt KF, DiGiovanni CW. Injury patterns causing isolated foot compartment syndrome. J Bone Joint Surg Am. 2012;94(11): 1030-1035. 13. Thiagarajan P, Neeta S, Das De S. Forklift related injuries. J Orthop Surg. 1998;6(2):11.
Downloaded from fai.sagepub.com at Bobst Library, New York University on July 2, 2015
