- Email: [email protected]
Empty Toe Phenomenon: A Rare Presentation of Closed Degloving Injury of the Foot
The Journal of Foot & Ankle Surgery xxx (2015) 1–8
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
Case Reports and Series
Empty Toe Phenomenon: A Rare Presentation of Closed Degloving Injury of the Foot Adam L. Bingham, DPM 1, Lawrence M. Fallat, DPM, FACFAS 2 1 2
Foot and Ankle Specialty Clinic, Russellville, AR Diplomate, America Board of Podiatric Surgery, Director, Podiatric Surgical Residency, Beaumont Hospital–Wayne, Wayne, MI
a r t i c l e i n f o
a b s t r a c t
Level of Clinical Evidence: 4
Traumatic degloving injuries of the lower extremity are commonly diagnosed by soft tissue deficits and separation of soft tissue planes. The management of open degloving injuries is well documented with established treatment protocols. Because closed degloving injuries of the lower extremity are so rare, the protocol management is not well established. Unlike open degloving injuries, evidence of soft tissue injury and detachment of the tissue planes can be subtle. Owing to the rarity of these injuries, little has been described regarding the long-term outcomes. In the present report, 2 closed degloving cases are presented. The first case presented is of a 27-year-old railroad worker who sustained a severe closed degloving injury of his foot with digital soft tissue envelope transposition. The second case involved a 60-year-old automobile manufacturer, whose foot was crushed by a hydraulic fork lift, creating a degloving injury of the third, fourth, and fifth toes. The follow-up duration from the date of injury for patient 1 was 26 months and for patients 2 was 16 months. The purpose of presenting these cases is to report these rare injuries with the treatment, complications, and outcomes. Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved.
Keywords: compartment syndrome crush injury empty toe e injury Morel-Lavalle trauma
Traumatic open degloving injuries typically present with varying amounts of partially or completely detached skin and soft tissue. These injuries are easy to visualize and diagnose by the obvious tears and detachment of tissue. Because open degloving injuries are more common, many case studies and studies have been reported describing various protocols for treatment with both short- and long-term outcomes. Closed degloving injuries are rare and occur as a result of a violent shearing force applied across the skin surface that separates the skin and subcutaneous soft tissue from the deeper fascia planes without rupture of the dermal or epidermal tissue plane. The shear force transects the perforating vessel anastomoses between the tissue planes, creating a resultant void, liquefied fat necrosis, and vascular injury (1,2). This results in large hematoma formation, venous congestion, and inhibition of revascularization of the superficial tissue. The detached tissue then relies primarily on the subdermal plexus for its nutrient supply. Often, the loss of the blood supply results in rapid gangrenous necrosis of the superficial soft tissues. From our review of the peer-reviewed published data, only 5 cases have been documented describing “empty-toe” and “closed degloving
injuries” specific to the lower extremity. The earliest case was reported by Matelic and Manoli (3) in 1994. They described a crush injury with degloving and translocation of the fifth digit into the fourth web space. This was managed with simple closed reduction, which restored the blood flow. The patient was placed in a cast shoe for 1 week, after which he returned to his normal activities with no subsequent complications (3). In 1998, Flaherty et al (4) described a similar traumatic crush injury involving the second digit with transposition of the distal and intermediate phalanx vertically beneath the proximal phalanx. Because of the severity of the crush injury, the digital soft tissue envelopes were unsalvageable, and the patient underwent transmetatarsal amputation (4). Additional cases have been reported by Tarleton et al (5), Singh and Downing (6), and Tang et al (7), who all described fifth digit degloving and translocation to the fourth web space. All 3 cases resulted in surgical amputation or auto-amputation of the affected digit. The purpose of the present report was to report 2 cases of these rare injuries with the treatment, complications, and outcomes. Case Report
Financial Disclosure: None reported. Conflict of Interest: None reported. Address correspondence to: Lawrence M. Fallat, DPM, FACFAS, Podiatric Surgical Residency, Beaumont Hospital–Wayne, 33155 Annapolis Street, Wayne, MI 48184. E-mail address: [email protected] (L.M. Fallat).
Patient 1 A 27-year-old male railroad worker was treated from September 2012 through November 2014. He presented to the emergency
1067-2516/$ - see front matter Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2015.06.018
2
A.L. Bingham, L.M. Fallat / The Journal of Foot & Ankle Surgery xxx (2015) 1–8
Fig. 1. (A) View showing significant edema and separation of toes. (B) No resistance was present with dorsiflexion of digits.
department (ED) after injuring his right foot while at work. As a railroad employee, he was riding on a gondola train car and was trying to engage the hand brake when he slipped. In an attempt to prevent falling, he grasped the side ladder of the railroad car, but his right foot slid in front of the train car wheel and was crushed. The patient presented to our institution’s ED for evaluation. He was in good health without a significant medical or surgical history. He had allergies to penicillin, mangos, and whole wheat. His family history was significant for stroke, diabetes mellitus, and arthritis; his social history was noncontributory. The patient was not taking any home medications. At the initial presentation, he was alert and oriented with a Glasgow coma scale score of 15, with the injury localized only to the foot, without extension to the ankle, knee, hip, abdomen, head, neck, or back. No other penetrating trauma was identified. The lower extremity examination revealed intact biphasic dorsalis pedis and posterior tibial pulses. The patient had significant 2 plus edematous soft tissue changes, and a superficial 2-cm laceration medial to the navicular tuberosity (Fig. 1). The patient was unable to move the lesser digits, and fluctuance of toes 2 through 5 was present, with no resistance to manipulation. Sensation was mildly diminished to the hallux but intact to the remainder of the foot. The patient’s pain was 10 of 10 on the visual analog scale for pain that decreased to 6 of 10 with intravenous hydromorphone. Radiographs and computed tomography (CT) of his right foot revealed dislocation of the right hallux interphalangeal joint and dislocation and translocation of the right second digit (proximal, intermediate, and a segmental portion of the distal phalanx), with reentry into the hallux soft tissue envelope. Complete translocation of the third digit (proximal, intermediate, and distal phalanx) had occurred, with reentry into the second digit soft tissue envelope. The fifth digit was also transposed, with reentry into the fourth digit soft tissue envelope, in conjunction with the fourth digit, and a nondisplaced cuboid fracture and fracture involving the first tarsometatarsal joint (Fig. 2). Additional radiographs of the
patient’s knee, tibia, fibula, and ankle revealed unremarkable findings. Neurovascular checks performed every hour revealed a progressive decrease of sensation to the toes. At 4 hours after the initial ED evaluation, the loss of sensation had progressed from the great toe to the lesser toes and had extended proximally to the level of the metatarsophalangeal joints. Because compartment syndrome was suspected, immediate surgical intervention was recommended. The procedures were planned to include compartment pressure measurement with decompression if indicated and reduction of the translocated digits. The patient was taken to surgery directly from our institution’s ED. Spinal anesthesia was performed, and the patient received clindamycin 300 mg intravenously preoperatively. Using compartmental pressure instrumentation, the intracompartmental pressure was 75 mm Hg in the second interosseous space, 64 mm Hg in the third, 60 mm Hg in the deep central, 25 mm Hg in the lateral, and 28 mm Hg in the medial compartment. Fasciotomies of the second and third interosseous and deep central compartments were performed. Closed reduction of the translocated toes was performed with intraoperative fluoroscopic assistance. Gentle distraction and closed reduction was successful in relocating the fourth and fifth digits. Toes 2 and 3 were nonreducible by this technique, and surgical relocation into their respective soft tissue envelopes was accomplished through dorsal incisions and manual relocation. Because none of the digits would remain in their soft tissue envelopes, Kirschner wires (K-wires) were used to maintain the reduction and stabilize toes 2 through 5 (Fig. 3). It was also noted that each digit had complete tears of the extensor tendons with retraction into the proximal foot. To minimize any additional trauma, it was thought that the tendons could be repaired at a later date. To prevent additional retraction, the tendons were tacked to the adjacent soft tissue with simple sutures. The interphalangeal joint of the great toe could not be reduced with a closed approach; thus, a lazy S incision was placed over the
A.L. Bingham, L.M. Fallat / The Journal of Foot & Ankle Surgery xxx (2015) 1–8
3
Fig. 2. Emergency department radiographs revealing the extent of digital translocation.
Fig. 3. Postoperative radiographs demonstrating alignment of digits.
interphalangeal joint. The bone fragments and soft tissue that had been blocking reduction were removed, and the dislocation was reduced and maintained with K-wires. A gradient compressive dressing was placed on his right lower extremity. The patient was returned to the floor for continued monitoring of his foot for early signs of necrosis, ischemic demarcation, and for pain control. Despite the open fasciotomy site, a large hematoma formed in the decompression site, along with large fracture blisters. Although he had a mild reduction in pain after surgery, his pain again progressed to 10 of 10 during the next 4 days. Evaluation revealed the capillary refill time to be intact, with increasing venous congestion; however, the pedal pulses had become nonpalpable. Sensation remained intact at the midfoot but was diminished to the digits. Signs of skin necrosis to the distal second toe were noted. Four days after his initial surgery, he was taken back to the operating room for evacuation of the hematoma. The intracompartmental pressures were measured again and found to be elevated to 50 mm Hg in the second and third interosseous spaces, 55 mm Hg in the deep central compartment, 52 mm Hg in the lateral compartment, and 38 mm Hg in the medial compartment. Aggressive fasciotomies were performed with evacuation of the hematoma. The superficial eschar
on the dorsal surface of the foot was debrided, revealing healthy skin beneath. The incision sites were loosely packed with gauze to assist with drainage. Sterile, mild compressive dressings were placed on the foot. The rest of his hospital course was uneventful, and his pain had decreased to a manageable level. The patient was discharged 2 days later with instructions to return to our outpatient clinic for follow-up examinations. The patient was seen regularly for serial wound debridement and fluid drainage. Dry gangrenous changes developed at the distal aspect of toes 1 through 5, extending proximally to the level of the midfoot dorsally (Fig. 4). During serial debridement, auto-amputation of the third and fifth toes occurred. Because of the extent of the dry gangrene, transmetatarsal amputation was recommended but was adamantly refused by the patient. Partial digital amputations were performed with debridement of the gangrenous skin 3.5 months after the initial injury. At 6 months after the original injury, his foot had completely healed, and he was ambulating with minor discomfort. The discomfort resulted from his foot sliding distally in his shoe. Custom orthotic devices with a spacer on the right orthotic were fabricated. The patient gradually developed a constant burning pain to the distal aspect of his foot, with the greatest pain located in the
4
A.L. Bingham, L.M. Fallat / The Journal of Foot & Ankle Surgery xxx (2015) 1–8
Fig. 4. Extensive dry gangrenous changes to the dorsal (A) and plantar (B) aspects of the foot.
third intermetatarsal space, extending from dorsally to plantarly at the distal aspect of his foot and along the course of the intermediate dorsal cutaneous nerve. Treatment consisting of nonsteroidal antiinflammatory medications and serial peripheral nerve blocks were only mildly successful at reducing his pain. The patient was then referred to a pain specialist for evaluation and treatment. At 7 months after his initial injury, complex regional pain syndrome type 2, as described by the International Association for the Study of Pain, was diagnosed (8). For treatment, he received several sympathetic nerve blocks and was prescribed additional oral neurologic medication. Although he had mild improvement, the pain continued to persist, with a range of 3 to 7 of 10 on the visual analog scale. The focal point of the pain was located in the distal third intermetatarsal space. Because of the persistent continuous severe pain, digital fibrosis, and stiffness of the metatarsophalangeal joints, the patient agreed to a transmetatarsal amputation. The procedure was performed using spinal anesthesia in an attempt to reduce exacerbation of the complex regional pain syndrome. His postoperative course was unremarkable. Once the surgical site had healed, he was ambulatory with a pain level of 2 to 3 of 10 (Fig. 5). At the latest follow-up examination, the patient was >2 years from his date of injury and had retrained for a more sedentary type of employment. Patient 2 A 60-year-old male, treated from November 2013 through March 2015, had sustained a crush injury when a hydraulic fork lift was driven over his left foot while he was at work. He presented to our ED for evaluation approximately 2 hours after the accident. The patient had no significant medical or surgical history, and his family history was unremarkable. He had no known drug allergies and was not taking any medications. The physical evaluation performed by the emergency department physician revealed no other trauma. The patient graded his pain level at 4 of 10, with the severity of the pain increasing. The lower extremity examination revealed that the dorsalis pedis and posterior tibial arteries were intact and easily palpable.
The capillary refill time was <3 seconds to toes 1 through 4. The capillary refill time to the fifth toe was 7 seconds; the toe was cool to touch and was essentially a flail toe. The soft tissue envelope surrounding the third and fourth toes felt loose with palpation and disconnected from the underlying osseous structures. Toes 2 through 5 demonstrated superficial abrasions and subungual discoloration consistent with hematoma (Fig. 6). Sensation and motor function were intact to toes 1 through 4 but were not to the fifth toe. Radiographic examination demonstrated transposition of the fifth digit into the fourth web space and distal tuft fractures of the distal phalanges of digits 3 through 5, with satisfactory alignment (Fig. 7). Using a local anesthetic in the ED, closed reduction with insertion of the phalanges of the fifth toe into its soft tissue envelope was attempted but was not successful. The patient was taken to surgery directly from our institution’s ED. Preoperatively, the antibiotic cefazolin 2 g intravenously was administered. Using compartmental pressure instrumentation, the intracompartmental pressure measurements revealed the fourth interossei compartment to be elevated to 57 mm Hg. The deep central, medial, and lateral compartments had measured pressures of <30 mm Hg. A linear incision was made over the third intermetatarsal space, the hematoma was evacuated, and fasciotomy of the fourth interossei compartment was performed. Using intraoperative fluoroscopy, the fifth digit was successfully reduced with a closed approach, and the capillary refill time improved after reduction. A percutaneous K-wire was inserted to stabilize the fifth digit and distal tuft fracture and keep the toe in its soft tissue envelope (Fig. 8). The incision site was then flushed with copious amounts of antibiotic irrigation, and a drain was inserted in the fasciotomy site. Horizontal sutures were used on the dorsal surface of toes 3 through 5 to reduce the void created by the degloving injury and prevent hematoma formation. Three loose retention sutures were placed across the fasciotomy site, and a mild compressive dressing was applied. The postoperative hospital course was uneventful, and his pain had decreased to a manageable level. The patient was discharged 1 day postoperatively.
A.L. Bingham, L.M. Fallat / The Journal of Foot & Ankle Surgery xxx (2015) 1–8
5
Fig. 5. Healed transmetatarsal amputation.
Fig. 6. Clinical appearance of degloving injury.
At the first postoperative clinic visit, the fifth toe was darkened and appeared to be developing dry gangrene necrosis. Pain was rated as 3 of 10, and perfusion to digits 1 through 4 was intact, with capillary refill times of <3 seconds. The patient continued to return every 2 weeks for additional evaluation. At week 4, the K-wire was removed, and the dry, black, superficial necrotic tissue of the fifth toe was debrided, revealing healthy pink vascular skin. At 6 weeks, the patient was allowed to advance to full weightbearing and begin physical therapy. At 10 weeks after the injury and surgery, the patient developed left lower extremity swelling and pain in his left calf. He was sent for a duplex ultrasound scan, which revealed a deep vein thrombosis. Physical therapy was temporally discontinued until the clot had resolved. The patient has residual neuritic pain to the distal medial dorsal cutaneous nerve. He has undergone several peripheral nerve blocks using local anesthetics with steroids and continues to have improvement in his function and pain levels (Fig. 9). The latest followup visit was 16 months from the date of injury. His treatment has been completed; however, owing to the chronic pain, he has been unable to return to work and receives disability.
The outcomes of both reconstruction and amputation have been found to be equally satisfactory at the 2-year follow-up point (10). Patients prefer their own foot, even with a deformity, to a prosthesis, although the return to work activities might be quicker with amputation (11). If salvage of the useful portion of the foot with appropriate bone length and soft tissue coverage is possible, it is strongly recommended (12). Both of our patients presented with rare closed degloving injuries with translocated digits. Both patients requested that every attempt be made to avoid amputation of their toes and feet. Ultimately, the first case was unsalvageable, and a transmetatarsal amputation was eventually performed. In the second patient, because the injury was not as severe, amputation was avoided. Only 5 case studies were found in our peer-reviewed published data search describing closed degloving injuries involving the lower extremity. Of these reports, only 1 demonstrated a positive outcome without any significant complications. The other 4 cases ended with amputation of the affected toes (3–7). Complications from degloving injuries arise from continued tissue loss, infection, hematoma, seroma formation, tissue contracture, and neuritis (13). Undiagnosed or untreated compartment syndrome is also a complication occurring after severe crush injuries that can have long-lasting effects (14–17). When presented with rare traumatic injuries, the surgeon should consider treatment protocols from similar types of injuries. Morele, a French physician, described a closed degloving injury that Lavalle occurs at multiple body regions, including the greater trochanter, trunk, lumbar, prepatellar, and scapular regions (1,13,18–20). Up to
Discussion Degloving injuries of the lower extremities can be challenging to manage. Because of the severity of these injuries, attempts to salvage traumatized limbs commonly end with devitalized tissue and unpreventable amputation. Scoring systems have been used to determine whether patients will benefit from amputation versus reconstruction; however, these systems have proved unreliable (9).
6
A.L. Bingham, L.M. Fallat / The Journal of Foot & Ankle Surgery xxx (2015) 1–8
Fig. 7. Emergency department radiographs revealing translocation of the fifth toe into the fourth web space.
Fig. 8. Postoperative radiographs showing alignment of fifth toe.
one third of closed degloving injuries in other body regions have been reported to be undiagnosed or misdiagnosed (18). The risk of the degloved tissue becoming necrotic in these regions is lower owing to better vascular anastomoses. Thus, the outcomes will be more successful. Lin et al (19) described the treatment of an 18-yearold male who had sustained a closed degloving injury from a scooter accident. The patient was assessed in the emergency department and discharged, only to return 2 days later with complaints of painful fluctuant fluid in the proximal lateral aspect of both thighs, with communication proximally to the lumbosacral region. The patient was treated with aspiration, drainage, and compressive dressings. The fluid collection gradually resolved over a 10-month period with no tissue necrosis. These investigators described 2 types of closed degloving injuries: those treatable nonoperatively without a major fracture or skin necrosis and those requiring surgical debridement (19). Morris et al (13) reported a case treated with vacuum-assisted closure. A 27-year-old male had sustained multiple lacerations, an internal injury, and a large subcutaneous fluid collection to the left flank during an all-terrain vehicle accident. Computed tomography revealed a large closed degloving injury with subcutaneous hematoma formation on his left flank. On day 3 of hospitalization, the patient was taken to surgery to evacuate the hematoma. After evacuation, the cavernous void was explored and found to involve 50% of his back and hip. Wound vacuum-assisted closure (VAC) was used in an attempt to drain the fluid and salvage the degloved skin. On day 6, it was determined that the wound VAC had been successful in the hip region; however, accumulation persisted on the patient’s
back. The patient was taken back to surgery, and an additional incision and wound VAC was placed. At day 10, the wound VAC was changed, and the hip incision site was partially closed. The patient was discharged from the hospital and returned 3 days later for outpatient removal of the VAC devices and delayed primary closure. The patient’s closed degloving injury was successfully treated, and he returned to work without recurrence, wound contractures, or complications (13). Hyperbaric treatment can also be used to augment treatment and wound healing. In a 2013 Cochrane review, hyperbaric oxygen treatment of crush injuries was reviewed (21). The study by Bouachour et al (22) met their criteria. They had performed a blinded randomized study of 36 patients treated with hyperbaric oxygen. The patients in the treatment group received 100% oxygen at 2.5 atm absolute for 90 minutes twice daily for 6 days. The sham groups were given 21% oxygen at 1.1 atm absolute for the same period and length of time. Overall, the patients in the treatment group had a greater occurrence of complete healing and lower amputation rates (22). Open degloving injury treatment protocols could also prove helpful in considering the treatment options for closed degloving injuries. The published data for management of open degloving injuries have reported lower complications, including soft tissue infection, osteomyelitis, and flap failure, with aggressive debridement and early flap coverage within 3 to 4 days of injury (23). Reconstruction of total degloving injuries should include serial debridement, adipocutaneous flaps, or muscle flaps for weightbearing surfaces, split-thickness skin grafts, and free flaps
A.L. Bingham, L.M. Fallat / The Journal of Foot & Ankle Surgery xxx (2015) 1–8
7
therapy to restore function although was unable to return to work. However, the patient was able to successfully perform activities of daily living (30). Husain and Fallat (31) described treatment of necrotic gangrenous skin resulting from an open degloving injury using maggot therapy. We have presented 2 cases of rare closed degloving injuries of the foot with descriptions of the initial presentation, management, complications, and outcomes. Our treatment included surgical reduction, fasciotomies, hematoma evacuation, postdemarcation debridement, and amputation. The patient who developed complex regional pain syndrome was treated by a pain specialist/anesthesiologist. Additional treatment options include serial drainage, segmental grafting, and hyperbaric oxygen therapy. Wound VAC therapy can be beneficial in an open degloving injury but cannot be used on a closed degloving injury unless an incision is made for fasciotomy or hematoma evacuation. In conclusion, closed degloving injuries of the foot are severe soft tissue injuries that can have poor outcomes, regardless of the treatment. Owing to the extent of the injury, the digits or limb might not be salvageable. References
Fig. 9. Healed degloving injury.
containing less subcutaneous tissue for dorsal skin coverage (24,25). Hollenbeck et al (26) described 161 patients who had undergone free flap application from 10 donor sites, revealing that functional subunit application was dependent on the application location. Their study demonstrated an 89% Kaplan-Meier 5-year salvage rate (26). Yan et al (27,28) reported successful treatment outcomes for degloved skin at variable levels of the leg. Their protocol consisted of wound debridement and skin defatting, radical debridement of nonviable tissue, and re-creation of the fascia planes with a fascia flap covering bone and tendon (27,28). The skin was fenestrated for drainage of seroma and hematoma and was stabilized with sutures. Bolster dressings were applied to conform to the anatomic contour, using gauze balls to ensure constant contact between the grafts and underlying tissue. A padded dressing with plaster splints was applied for 7 to 10 days. The mean follow-up period was 2 years, with complete graft incorporation occurring in 20 of the 21 patients. Seventeen patients had good to excellent Maryland foot scores, and all the patients were satisfied with the cosmetic appearance (27). Zagrocki et al (29) demonstrated treatment of degloving injuries with a triple-layer small intestine submucosa wound matrix, VAC therapy, and subsequent split-thickness skin grafts. Their patient healed successfully with a full return to activities (29). Similarly, Wong et al (30) described VAC therapy for preparation of a degloved limb wound bed. After approximately 21 days, the patient underwent grafting with a split-thickness skin graft and was discharged on postoperative day 16. The patient subsequently underwent physical
e lesion. Am J Orthop 39:252–253, 1. Chokshi FH, Jose J, Clifford PD. Morel-Lavalle 2010. 2. de Korte N, Dwars BJ, van der Werff JF. Degloving injury of an extremity: is primary closure obsolete? J Trauma 67:60–61, 2009. 3. Matelic TM, Manoli A II. Closed degloving injury of the fifth toe. J Orthop Trauma 8:265–266, 1994. 4. Flaherty JD, Evans DA, Danahy PR. The empty toe phenomenon: a type of closed degloving. Am J Orthop 27:524–525, 1998. 5. Tarleton AA, Faust KC, Davis JA. Empty toe phenomenon: a big problem for a little toe. Skeletal Radiol 43:71–74, 2014. 6. Singh HP, Downing ND. An “empty” toe. Foot 15:114–116, 2005. 7. Tang CL, Lee SS, Lin TY, Lin YK, Yeh YS, Lin HL, Lee WC, Chen CW. Empty toe: a unique type of closed degloving injury with dismal outcome. Am J Emerg Med 31:263.e1–263.e3, 2013. 8. Merskey H, Bogduk N. Classification of Chronic Pain: Descriptions of Chronic Pain Syndromes and Definitions of Pain Terms, ed 2., IASP Press, Seattle, 1994. 9. Bosse MJ, MacKenzie EJ, Kellam JF, Burgess AR, Webb LX, Swiontkowski MF, Sanders RW, Jones AL, McAndrew MP, Patterson BM, McCarthy ML, Cyril JK. A prospective evaluation of the clinical utility of the lower-extremity injury-severity scores. J Bone Joint Surg Am 83:3–14, 2001. 10. Bosse MJ, MacKenzie EJ, Kellam JF, Burgess AR, Webb LX, Swiontkowski MF, Sanders RW, Jones AL, McAndrew MP, Patterson BM, McCarthy ML, Travison TG, Castillo RC. An analysis of outcomes of reconstruction or amputation after legthreatening injuries. N Engl J Med 347:1924–1931, 2002. 11. Francel TJ, Vander Kolk CA, Hoopes JE, Manson PN, Yaremchuk MJ. Microvascular soft-tissue transplantation for reconstruction of acute open tibial fractures: timing of coverage and long-term functional results. Plast Reconstr Surg 89:478–487, 1992. 12. Bowker JH. Partial foot amputations and disarticulations: surgical aspects. J Prosthet Orthot 19:62–76, 2007. 13. Morris M, Schreiber MA, Ham B. Novel management of closed degloving injuries. J Trauma 67:121–123, 2009. 14. Yoon P. Compartment syndrome of the foot. Techn Orthop 27:58–61, 2012. 15. Myerson M. Diagnosis and treatment of compartment syndrome of the foot. Orthopedics 13:711–717, 1990. 16. Smith GH. Measurement of the intracompartmental pressures of the foot. J Foot Surg 29:589–592, 1990. 17. Manoli A II. Compartment syndromes of the foot: current concepts. Foot Ankle 10:340–344, 1990. e lesion in children. World J 18. Rha EY, Kim DH, Kwon H, Jung SN. Morel-Lavalle Emerg Surg 8:60, 2013. 19. Lin HL, Lee WC, Kuo LC, Chen CW. Closed internal degloving injury with conservative treatment. Am J Emerg Med 26:254.e5–254.e6, 2008. 20. Hudson DA, Knottenbelt JD, Krige JE. Closed degloving injuries: results following conservative surgery. Plast Reconstr Surg 89:853–855, 1992. 21. Eskes A, Vermeulen H, Lucas C, Ubbink DT. Hyperbaric oxygen therapy for treating acute surgical and traumatic wounds. Cochrane Database Syst Rev 12:CD008059, 2013. 22. Bouachour G, Cronier P, Gouello JP, Toulemonde JL, Talha A, Alquier P. Hyperbaric oxygen therapy in the management of crush injuries: a randomized double-blind placebo-controlled clinical trial. J Trauma 41:333–339, 1996. 23. Hudson DA. Missed closed degloving injuries: late presentation as a contour deformity. Plast Reconstr Surg 98:334–337, 1996.
8
A.L. Bingham, L.M. Fallat / The Journal of Foot & Ankle Surgery xxx (2015) 1–8
24. Baumeister S, Radu CA. Salvage reconstruction of the severely traumatized foot and ankle. Tech Orthop 24:96–107, 2009. 25. Liu DX, Li XD, Wang H, Qiu KF, Du SX. Reconstruction of total degloving injuries of the foot in children. J Trauma Acute Care Surg 73:209–214, 2012. 26. Hollenbeck ST, Woo S, Komatsu I, Erdmann D, Zenn MR, Levin LS. Longitudinal outcomes and application of the subunit principle to 165 foot and ankle free tissue transfers. Plast Reconstr Surg 125:924–934, 2010. 27. Yan H, Gao W, Li Z, Wang C, Liu S, Zhang F, Fan C. The management of degloving injury of lower extremities: technical refinement and classification. J Trauma Acute Care Surg 74:604–610, 2013.
28. Yan H, Liu S, Gao W, Li Z, Chen X, Wang C, Zhang F, Fan C. Management of degloving injuries of the foot with a defatted full-thickness skin graft. J Bone Joint Surg Am 95:1675–1681, 2013. 29. Zagrocki L, Ross A, Hicks A. Management of degloving injuries of the lower extremity: a case report of a forklift injury. Foot Ankle Spec 6:150–153, 2013. 30. Wong LK, Nesbit RD, Turner LA, Sargent LA. Management of a circumferential lower extremity degloving injury with the use of vacuum-assisted closure. South Med J 99:628–630, 2006. 31. Husain ZS, Fallat LM. Maggot therapy for wound debridement in a traumatic footdegloving injury: a case report. J Foot Ankle Surg 42:371–376, 2003.
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
Case Reports and Series
Empty Toe Phenomenon: A Rare Presentation of Closed Degloving Injury of the Foot Adam L. Bingham, DPM 1, Lawrence M. Fallat, DPM, FACFAS 2 1 2
Foot and Ankle Specialty Clinic, Russellville, AR Diplomate, America Board of Podiatric Surgery, Director, Podiatric Surgical Residency, Beaumont Hospital–Wayne, Wayne, MI
a r t i c l e i n f o
a b s t r a c t
Level of Clinical Evidence: 4
Traumatic degloving injuries of the lower extremity are commonly diagnosed by soft tissue deficits and separation of soft tissue planes. The management of open degloving injuries is well documented with established treatment protocols. Because closed degloving injuries of the lower extremity are so rare, the protocol management is not well established. Unlike open degloving injuries, evidence of soft tissue injury and detachment of the tissue planes can be subtle. Owing to the rarity of these injuries, little has been described regarding the long-term outcomes. In the present report, 2 closed degloving cases are presented. The first case presented is of a 27-year-old railroad worker who sustained a severe closed degloving injury of his foot with digital soft tissue envelope transposition. The second case involved a 60-year-old automobile manufacturer, whose foot was crushed by a hydraulic fork lift, creating a degloving injury of the third, fourth, and fifth toes. The follow-up duration from the date of injury for patient 1 was 26 months and for patients 2 was 16 months. The purpose of presenting these cases is to report these rare injuries with the treatment, complications, and outcomes. Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved.
Keywords: compartment syndrome crush injury empty toe e injury Morel-Lavalle trauma
Traumatic open degloving injuries typically present with varying amounts of partially or completely detached skin and soft tissue. These injuries are easy to visualize and diagnose by the obvious tears and detachment of tissue. Because open degloving injuries are more common, many case studies and studies have been reported describing various protocols for treatment with both short- and long-term outcomes. Closed degloving injuries are rare and occur as a result of a violent shearing force applied across the skin surface that separates the skin and subcutaneous soft tissue from the deeper fascia planes without rupture of the dermal or epidermal tissue plane. The shear force transects the perforating vessel anastomoses between the tissue planes, creating a resultant void, liquefied fat necrosis, and vascular injury (1,2). This results in large hematoma formation, venous congestion, and inhibition of revascularization of the superficial tissue. The detached tissue then relies primarily on the subdermal plexus for its nutrient supply. Often, the loss of the blood supply results in rapid gangrenous necrosis of the superficial soft tissues. From our review of the peer-reviewed published data, only 5 cases have been documented describing “empty-toe” and “closed degloving
injuries” specific to the lower extremity. The earliest case was reported by Matelic and Manoli (3) in 1994. They described a crush injury with degloving and translocation of the fifth digit into the fourth web space. This was managed with simple closed reduction, which restored the blood flow. The patient was placed in a cast shoe for 1 week, after which he returned to his normal activities with no subsequent complications (3). In 1998, Flaherty et al (4) described a similar traumatic crush injury involving the second digit with transposition of the distal and intermediate phalanx vertically beneath the proximal phalanx. Because of the severity of the crush injury, the digital soft tissue envelopes were unsalvageable, and the patient underwent transmetatarsal amputation (4). Additional cases have been reported by Tarleton et al (5), Singh and Downing (6), and Tang et al (7), who all described fifth digit degloving and translocation to the fourth web space. All 3 cases resulted in surgical amputation or auto-amputation of the affected digit. The purpose of the present report was to report 2 cases of these rare injuries with the treatment, complications, and outcomes. Case Report
Financial Disclosure: None reported. Conflict of Interest: None reported. Address correspondence to: Lawrence M. Fallat, DPM, FACFAS, Podiatric Surgical Residency, Beaumont Hospital–Wayne, 33155 Annapolis Street, Wayne, MI 48184. E-mail address: [email protected] (L.M. Fallat).
Patient 1 A 27-year-old male railroad worker was treated from September 2012 through November 2014. He presented to the emergency
1067-2516/$ - see front matter Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2015.06.018
2
A.L. Bingham, L.M. Fallat / The Journal of Foot & Ankle Surgery xxx (2015) 1–8
Fig. 1. (A) View showing significant edema and separation of toes. (B) No resistance was present with dorsiflexion of digits.
department (ED) after injuring his right foot while at work. As a railroad employee, he was riding on a gondola train car and was trying to engage the hand brake when he slipped. In an attempt to prevent falling, he grasped the side ladder of the railroad car, but his right foot slid in front of the train car wheel and was crushed. The patient presented to our institution’s ED for evaluation. He was in good health without a significant medical or surgical history. He had allergies to penicillin, mangos, and whole wheat. His family history was significant for stroke, diabetes mellitus, and arthritis; his social history was noncontributory. The patient was not taking any home medications. At the initial presentation, he was alert and oriented with a Glasgow coma scale score of 15, with the injury localized only to the foot, without extension to the ankle, knee, hip, abdomen, head, neck, or back. No other penetrating trauma was identified. The lower extremity examination revealed intact biphasic dorsalis pedis and posterior tibial pulses. The patient had significant 2 plus edematous soft tissue changes, and a superficial 2-cm laceration medial to the navicular tuberosity (Fig. 1). The patient was unable to move the lesser digits, and fluctuance of toes 2 through 5 was present, with no resistance to manipulation. Sensation was mildly diminished to the hallux but intact to the remainder of the foot. The patient’s pain was 10 of 10 on the visual analog scale for pain that decreased to 6 of 10 with intravenous hydromorphone. Radiographs and computed tomography (CT) of his right foot revealed dislocation of the right hallux interphalangeal joint and dislocation and translocation of the right second digit (proximal, intermediate, and a segmental portion of the distal phalanx), with reentry into the hallux soft tissue envelope. Complete translocation of the third digit (proximal, intermediate, and distal phalanx) had occurred, with reentry into the second digit soft tissue envelope. The fifth digit was also transposed, with reentry into the fourth digit soft tissue envelope, in conjunction with the fourth digit, and a nondisplaced cuboid fracture and fracture involving the first tarsometatarsal joint (Fig. 2). Additional radiographs of the
patient’s knee, tibia, fibula, and ankle revealed unremarkable findings. Neurovascular checks performed every hour revealed a progressive decrease of sensation to the toes. At 4 hours after the initial ED evaluation, the loss of sensation had progressed from the great toe to the lesser toes and had extended proximally to the level of the metatarsophalangeal joints. Because compartment syndrome was suspected, immediate surgical intervention was recommended. The procedures were planned to include compartment pressure measurement with decompression if indicated and reduction of the translocated digits. The patient was taken to surgery directly from our institution’s ED. Spinal anesthesia was performed, and the patient received clindamycin 300 mg intravenously preoperatively. Using compartmental pressure instrumentation, the intracompartmental pressure was 75 mm Hg in the second interosseous space, 64 mm Hg in the third, 60 mm Hg in the deep central, 25 mm Hg in the lateral, and 28 mm Hg in the medial compartment. Fasciotomies of the second and third interosseous and deep central compartments were performed. Closed reduction of the translocated toes was performed with intraoperative fluoroscopic assistance. Gentle distraction and closed reduction was successful in relocating the fourth and fifth digits. Toes 2 and 3 were nonreducible by this technique, and surgical relocation into their respective soft tissue envelopes was accomplished through dorsal incisions and manual relocation. Because none of the digits would remain in their soft tissue envelopes, Kirschner wires (K-wires) were used to maintain the reduction and stabilize toes 2 through 5 (Fig. 3). It was also noted that each digit had complete tears of the extensor tendons with retraction into the proximal foot. To minimize any additional trauma, it was thought that the tendons could be repaired at a later date. To prevent additional retraction, the tendons were tacked to the adjacent soft tissue with simple sutures. The interphalangeal joint of the great toe could not be reduced with a closed approach; thus, a lazy S incision was placed over the
A.L. Bingham, L.M. Fallat / The Journal of Foot & Ankle Surgery xxx (2015) 1–8
3
Fig. 2. Emergency department radiographs revealing the extent of digital translocation.
Fig. 3. Postoperative radiographs demonstrating alignment of digits.
interphalangeal joint. The bone fragments and soft tissue that had been blocking reduction were removed, and the dislocation was reduced and maintained with K-wires. A gradient compressive dressing was placed on his right lower extremity. The patient was returned to the floor for continued monitoring of his foot for early signs of necrosis, ischemic demarcation, and for pain control. Despite the open fasciotomy site, a large hematoma formed in the decompression site, along with large fracture blisters. Although he had a mild reduction in pain after surgery, his pain again progressed to 10 of 10 during the next 4 days. Evaluation revealed the capillary refill time to be intact, with increasing venous congestion; however, the pedal pulses had become nonpalpable. Sensation remained intact at the midfoot but was diminished to the digits. Signs of skin necrosis to the distal second toe were noted. Four days after his initial surgery, he was taken back to the operating room for evacuation of the hematoma. The intracompartmental pressures were measured again and found to be elevated to 50 mm Hg in the second and third interosseous spaces, 55 mm Hg in the deep central compartment, 52 mm Hg in the lateral compartment, and 38 mm Hg in the medial compartment. Aggressive fasciotomies were performed with evacuation of the hematoma. The superficial eschar
on the dorsal surface of the foot was debrided, revealing healthy skin beneath. The incision sites were loosely packed with gauze to assist with drainage. Sterile, mild compressive dressings were placed on the foot. The rest of his hospital course was uneventful, and his pain had decreased to a manageable level. The patient was discharged 2 days later with instructions to return to our outpatient clinic for follow-up examinations. The patient was seen regularly for serial wound debridement and fluid drainage. Dry gangrenous changes developed at the distal aspect of toes 1 through 5, extending proximally to the level of the midfoot dorsally (Fig. 4). During serial debridement, auto-amputation of the third and fifth toes occurred. Because of the extent of the dry gangrene, transmetatarsal amputation was recommended but was adamantly refused by the patient. Partial digital amputations were performed with debridement of the gangrenous skin 3.5 months after the initial injury. At 6 months after the original injury, his foot had completely healed, and he was ambulating with minor discomfort. The discomfort resulted from his foot sliding distally in his shoe. Custom orthotic devices with a spacer on the right orthotic were fabricated. The patient gradually developed a constant burning pain to the distal aspect of his foot, with the greatest pain located in the
4
A.L. Bingham, L.M. Fallat / The Journal of Foot & Ankle Surgery xxx (2015) 1–8
Fig. 4. Extensive dry gangrenous changes to the dorsal (A) and plantar (B) aspects of the foot.
third intermetatarsal space, extending from dorsally to plantarly at the distal aspect of his foot and along the course of the intermediate dorsal cutaneous nerve. Treatment consisting of nonsteroidal antiinflammatory medications and serial peripheral nerve blocks were only mildly successful at reducing his pain. The patient was then referred to a pain specialist for evaluation and treatment. At 7 months after his initial injury, complex regional pain syndrome type 2, as described by the International Association for the Study of Pain, was diagnosed (8). For treatment, he received several sympathetic nerve blocks and was prescribed additional oral neurologic medication. Although he had mild improvement, the pain continued to persist, with a range of 3 to 7 of 10 on the visual analog scale. The focal point of the pain was located in the distal third intermetatarsal space. Because of the persistent continuous severe pain, digital fibrosis, and stiffness of the metatarsophalangeal joints, the patient agreed to a transmetatarsal amputation. The procedure was performed using spinal anesthesia in an attempt to reduce exacerbation of the complex regional pain syndrome. His postoperative course was unremarkable. Once the surgical site had healed, he was ambulatory with a pain level of 2 to 3 of 10 (Fig. 5). At the latest follow-up examination, the patient was >2 years from his date of injury and had retrained for a more sedentary type of employment. Patient 2 A 60-year-old male, treated from November 2013 through March 2015, had sustained a crush injury when a hydraulic fork lift was driven over his left foot while he was at work. He presented to our ED for evaluation approximately 2 hours after the accident. The patient had no significant medical or surgical history, and his family history was unremarkable. He had no known drug allergies and was not taking any medications. The physical evaluation performed by the emergency department physician revealed no other trauma. The patient graded his pain level at 4 of 10, with the severity of the pain increasing. The lower extremity examination revealed that the dorsalis pedis and posterior tibial arteries were intact and easily palpable.
The capillary refill time was <3 seconds to toes 1 through 4. The capillary refill time to the fifth toe was 7 seconds; the toe was cool to touch and was essentially a flail toe. The soft tissue envelope surrounding the third and fourth toes felt loose with palpation and disconnected from the underlying osseous structures. Toes 2 through 5 demonstrated superficial abrasions and subungual discoloration consistent with hematoma (Fig. 6). Sensation and motor function were intact to toes 1 through 4 but were not to the fifth toe. Radiographic examination demonstrated transposition of the fifth digit into the fourth web space and distal tuft fractures of the distal phalanges of digits 3 through 5, with satisfactory alignment (Fig. 7). Using a local anesthetic in the ED, closed reduction with insertion of the phalanges of the fifth toe into its soft tissue envelope was attempted but was not successful. The patient was taken to surgery directly from our institution’s ED. Preoperatively, the antibiotic cefazolin 2 g intravenously was administered. Using compartmental pressure instrumentation, the intracompartmental pressure measurements revealed the fourth interossei compartment to be elevated to 57 mm Hg. The deep central, medial, and lateral compartments had measured pressures of <30 mm Hg. A linear incision was made over the third intermetatarsal space, the hematoma was evacuated, and fasciotomy of the fourth interossei compartment was performed. Using intraoperative fluoroscopy, the fifth digit was successfully reduced with a closed approach, and the capillary refill time improved after reduction. A percutaneous K-wire was inserted to stabilize the fifth digit and distal tuft fracture and keep the toe in its soft tissue envelope (Fig. 8). The incision site was then flushed with copious amounts of antibiotic irrigation, and a drain was inserted in the fasciotomy site. Horizontal sutures were used on the dorsal surface of toes 3 through 5 to reduce the void created by the degloving injury and prevent hematoma formation. Three loose retention sutures were placed across the fasciotomy site, and a mild compressive dressing was applied. The postoperative hospital course was uneventful, and his pain had decreased to a manageable level. The patient was discharged 1 day postoperatively.
A.L. Bingham, L.M. Fallat / The Journal of Foot & Ankle Surgery xxx (2015) 1–8
5
Fig. 5. Healed transmetatarsal amputation.
Fig. 6. Clinical appearance of degloving injury.
At the first postoperative clinic visit, the fifth toe was darkened and appeared to be developing dry gangrene necrosis. Pain was rated as 3 of 10, and perfusion to digits 1 through 4 was intact, with capillary refill times of <3 seconds. The patient continued to return every 2 weeks for additional evaluation. At week 4, the K-wire was removed, and the dry, black, superficial necrotic tissue of the fifth toe was debrided, revealing healthy pink vascular skin. At 6 weeks, the patient was allowed to advance to full weightbearing and begin physical therapy. At 10 weeks after the injury and surgery, the patient developed left lower extremity swelling and pain in his left calf. He was sent for a duplex ultrasound scan, which revealed a deep vein thrombosis. Physical therapy was temporally discontinued until the clot had resolved. The patient has residual neuritic pain to the distal medial dorsal cutaneous nerve. He has undergone several peripheral nerve blocks using local anesthetics with steroids and continues to have improvement in his function and pain levels (Fig. 9). The latest followup visit was 16 months from the date of injury. His treatment has been completed; however, owing to the chronic pain, he has been unable to return to work and receives disability.
The outcomes of both reconstruction and amputation have been found to be equally satisfactory at the 2-year follow-up point (10). Patients prefer their own foot, even with a deformity, to a prosthesis, although the return to work activities might be quicker with amputation (11). If salvage of the useful portion of the foot with appropriate bone length and soft tissue coverage is possible, it is strongly recommended (12). Both of our patients presented with rare closed degloving injuries with translocated digits. Both patients requested that every attempt be made to avoid amputation of their toes and feet. Ultimately, the first case was unsalvageable, and a transmetatarsal amputation was eventually performed. In the second patient, because the injury was not as severe, amputation was avoided. Only 5 case studies were found in our peer-reviewed published data search describing closed degloving injuries involving the lower extremity. Of these reports, only 1 demonstrated a positive outcome without any significant complications. The other 4 cases ended with amputation of the affected toes (3–7). Complications from degloving injuries arise from continued tissue loss, infection, hematoma, seroma formation, tissue contracture, and neuritis (13). Undiagnosed or untreated compartment syndrome is also a complication occurring after severe crush injuries that can have long-lasting effects (14–17). When presented with rare traumatic injuries, the surgeon should consider treatment protocols from similar types of injuries. Morele, a French physician, described a closed degloving injury that Lavalle occurs at multiple body regions, including the greater trochanter, trunk, lumbar, prepatellar, and scapular regions (1,13,18–20). Up to
Discussion Degloving injuries of the lower extremities can be challenging to manage. Because of the severity of these injuries, attempts to salvage traumatized limbs commonly end with devitalized tissue and unpreventable amputation. Scoring systems have been used to determine whether patients will benefit from amputation versus reconstruction; however, these systems have proved unreliable (9).
6
A.L. Bingham, L.M. Fallat / The Journal of Foot & Ankle Surgery xxx (2015) 1–8
Fig. 7. Emergency department radiographs revealing translocation of the fifth toe into the fourth web space.
Fig. 8. Postoperative radiographs showing alignment of fifth toe.
one third of closed degloving injuries in other body regions have been reported to be undiagnosed or misdiagnosed (18). The risk of the degloved tissue becoming necrotic in these regions is lower owing to better vascular anastomoses. Thus, the outcomes will be more successful. Lin et al (19) described the treatment of an 18-yearold male who had sustained a closed degloving injury from a scooter accident. The patient was assessed in the emergency department and discharged, only to return 2 days later with complaints of painful fluctuant fluid in the proximal lateral aspect of both thighs, with communication proximally to the lumbosacral region. The patient was treated with aspiration, drainage, and compressive dressings. The fluid collection gradually resolved over a 10-month period with no tissue necrosis. These investigators described 2 types of closed degloving injuries: those treatable nonoperatively without a major fracture or skin necrosis and those requiring surgical debridement (19). Morris et al (13) reported a case treated with vacuum-assisted closure. A 27-year-old male had sustained multiple lacerations, an internal injury, and a large subcutaneous fluid collection to the left flank during an all-terrain vehicle accident. Computed tomography revealed a large closed degloving injury with subcutaneous hematoma formation on his left flank. On day 3 of hospitalization, the patient was taken to surgery to evacuate the hematoma. After evacuation, the cavernous void was explored and found to involve 50% of his back and hip. Wound vacuum-assisted closure (VAC) was used in an attempt to drain the fluid and salvage the degloved skin. On day 6, it was determined that the wound VAC had been successful in the hip region; however, accumulation persisted on the patient’s
back. The patient was taken back to surgery, and an additional incision and wound VAC was placed. At day 10, the wound VAC was changed, and the hip incision site was partially closed. The patient was discharged from the hospital and returned 3 days later for outpatient removal of the VAC devices and delayed primary closure. The patient’s closed degloving injury was successfully treated, and he returned to work without recurrence, wound contractures, or complications (13). Hyperbaric treatment can also be used to augment treatment and wound healing. In a 2013 Cochrane review, hyperbaric oxygen treatment of crush injuries was reviewed (21). The study by Bouachour et al (22) met their criteria. They had performed a blinded randomized study of 36 patients treated with hyperbaric oxygen. The patients in the treatment group received 100% oxygen at 2.5 atm absolute for 90 minutes twice daily for 6 days. The sham groups were given 21% oxygen at 1.1 atm absolute for the same period and length of time. Overall, the patients in the treatment group had a greater occurrence of complete healing and lower amputation rates (22). Open degloving injury treatment protocols could also prove helpful in considering the treatment options for closed degloving injuries. The published data for management of open degloving injuries have reported lower complications, including soft tissue infection, osteomyelitis, and flap failure, with aggressive debridement and early flap coverage within 3 to 4 days of injury (23). Reconstruction of total degloving injuries should include serial debridement, adipocutaneous flaps, or muscle flaps for weightbearing surfaces, split-thickness skin grafts, and free flaps
A.L. Bingham, L.M. Fallat / The Journal of Foot & Ankle Surgery xxx (2015) 1–8
7
therapy to restore function although was unable to return to work. However, the patient was able to successfully perform activities of daily living (30). Husain and Fallat (31) described treatment of necrotic gangrenous skin resulting from an open degloving injury using maggot therapy. We have presented 2 cases of rare closed degloving injuries of the foot with descriptions of the initial presentation, management, complications, and outcomes. Our treatment included surgical reduction, fasciotomies, hematoma evacuation, postdemarcation debridement, and amputation. The patient who developed complex regional pain syndrome was treated by a pain specialist/anesthesiologist. Additional treatment options include serial drainage, segmental grafting, and hyperbaric oxygen therapy. Wound VAC therapy can be beneficial in an open degloving injury but cannot be used on a closed degloving injury unless an incision is made for fasciotomy or hematoma evacuation. In conclusion, closed degloving injuries of the foot are severe soft tissue injuries that can have poor outcomes, regardless of the treatment. Owing to the extent of the injury, the digits or limb might not be salvageable. References
Fig. 9. Healed degloving injury.
containing less subcutaneous tissue for dorsal skin coverage (24,25). Hollenbeck et al (26) described 161 patients who had undergone free flap application from 10 donor sites, revealing that functional subunit application was dependent on the application location. Their study demonstrated an 89% Kaplan-Meier 5-year salvage rate (26). Yan et al (27,28) reported successful treatment outcomes for degloved skin at variable levels of the leg. Their protocol consisted of wound debridement and skin defatting, radical debridement of nonviable tissue, and re-creation of the fascia planes with a fascia flap covering bone and tendon (27,28). The skin was fenestrated for drainage of seroma and hematoma and was stabilized with sutures. Bolster dressings were applied to conform to the anatomic contour, using gauze balls to ensure constant contact between the grafts and underlying tissue. A padded dressing with plaster splints was applied for 7 to 10 days. The mean follow-up period was 2 years, with complete graft incorporation occurring in 20 of the 21 patients. Seventeen patients had good to excellent Maryland foot scores, and all the patients were satisfied with the cosmetic appearance (27). Zagrocki et al (29) demonstrated treatment of degloving injuries with a triple-layer small intestine submucosa wound matrix, VAC therapy, and subsequent split-thickness skin grafts. Their patient healed successfully with a full return to activities (29). Similarly, Wong et al (30) described VAC therapy for preparation of a degloved limb wound bed. After approximately 21 days, the patient underwent grafting with a split-thickness skin graft and was discharged on postoperative day 16. The patient subsequently underwent physical
e lesion. Am J Orthop 39:252–253, 1. Chokshi FH, Jose J, Clifford PD. Morel-Lavalle 2010. 2. de Korte N, Dwars BJ, van der Werff JF. Degloving injury of an extremity: is primary closure obsolete? J Trauma 67:60–61, 2009. 3. Matelic TM, Manoli A II. Closed degloving injury of the fifth toe. J Orthop Trauma 8:265–266, 1994. 4. Flaherty JD, Evans DA, Danahy PR. The empty toe phenomenon: a type of closed degloving. Am J Orthop 27:524–525, 1998. 5. Tarleton AA, Faust KC, Davis JA. Empty toe phenomenon: a big problem for a little toe. Skeletal Radiol 43:71–74, 2014. 6. Singh HP, Downing ND. An “empty” toe. Foot 15:114–116, 2005. 7. Tang CL, Lee SS, Lin TY, Lin YK, Yeh YS, Lin HL, Lee WC, Chen CW. Empty toe: a unique type of closed degloving injury with dismal outcome. Am J Emerg Med 31:263.e1–263.e3, 2013. 8. Merskey H, Bogduk N. Classification of Chronic Pain: Descriptions of Chronic Pain Syndromes and Definitions of Pain Terms, ed 2., IASP Press, Seattle, 1994. 9. Bosse MJ, MacKenzie EJ, Kellam JF, Burgess AR, Webb LX, Swiontkowski MF, Sanders RW, Jones AL, McAndrew MP, Patterson BM, McCarthy ML, Cyril JK. A prospective evaluation of the clinical utility of the lower-extremity injury-severity scores. J Bone Joint Surg Am 83:3–14, 2001. 10. Bosse MJ, MacKenzie EJ, Kellam JF, Burgess AR, Webb LX, Swiontkowski MF, Sanders RW, Jones AL, McAndrew MP, Patterson BM, McCarthy ML, Travison TG, Castillo RC. An analysis of outcomes of reconstruction or amputation after legthreatening injuries. N Engl J Med 347:1924–1931, 2002. 11. Francel TJ, Vander Kolk CA, Hoopes JE, Manson PN, Yaremchuk MJ. Microvascular soft-tissue transplantation for reconstruction of acute open tibial fractures: timing of coverage and long-term functional results. Plast Reconstr Surg 89:478–487, 1992. 12. Bowker JH. Partial foot amputations and disarticulations: surgical aspects. J Prosthet Orthot 19:62–76, 2007. 13. Morris M, Schreiber MA, Ham B. Novel management of closed degloving injuries. J Trauma 67:121–123, 2009. 14. Yoon P. Compartment syndrome of the foot. Techn Orthop 27:58–61, 2012. 15. Myerson M. Diagnosis and treatment of compartment syndrome of the foot. Orthopedics 13:711–717, 1990. 16. Smith GH. Measurement of the intracompartmental pressures of the foot. J Foot Surg 29:589–592, 1990. 17. Manoli A II. Compartment syndromes of the foot: current concepts. Foot Ankle 10:340–344, 1990. e lesion in children. World J 18. Rha EY, Kim DH, Kwon H, Jung SN. Morel-Lavalle Emerg Surg 8:60, 2013. 19. Lin HL, Lee WC, Kuo LC, Chen CW. Closed internal degloving injury with conservative treatment. Am J Emerg Med 26:254.e5–254.e6, 2008. 20. Hudson DA, Knottenbelt JD, Krige JE. Closed degloving injuries: results following conservative surgery. Plast Reconstr Surg 89:853–855, 1992. 21. Eskes A, Vermeulen H, Lucas C, Ubbink DT. Hyperbaric oxygen therapy for treating acute surgical and traumatic wounds. Cochrane Database Syst Rev 12:CD008059, 2013. 22. Bouachour G, Cronier P, Gouello JP, Toulemonde JL, Talha A, Alquier P. Hyperbaric oxygen therapy in the management of crush injuries: a randomized double-blind placebo-controlled clinical trial. J Trauma 41:333–339, 1996. 23. Hudson DA. Missed closed degloving injuries: late presentation as a contour deformity. Plast Reconstr Surg 98:334–337, 1996.
8
A.L. Bingham, L.M. Fallat / The Journal of Foot & Ankle Surgery xxx (2015) 1–8
24. Baumeister S, Radu CA. Salvage reconstruction of the severely traumatized foot and ankle. Tech Orthop 24:96–107, 2009. 25. Liu DX, Li XD, Wang H, Qiu KF, Du SX. Reconstruction of total degloving injuries of the foot in children. J Trauma Acute Care Surg 73:209–214, 2012. 26. Hollenbeck ST, Woo S, Komatsu I, Erdmann D, Zenn MR, Levin LS. Longitudinal outcomes and application of the subunit principle to 165 foot and ankle free tissue transfers. Plast Reconstr Surg 125:924–934, 2010. 27. Yan H, Gao W, Li Z, Wang C, Liu S, Zhang F, Fan C. The management of degloving injury of lower extremities: technical refinement and classification. J Trauma Acute Care Surg 74:604–610, 2013.
28. Yan H, Liu S, Gao W, Li Z, Chen X, Wang C, Zhang F, Fan C. Management of degloving injuries of the foot with a defatted full-thickness skin graft. J Bone Joint Surg Am 95:1675–1681, 2013. 29. Zagrocki L, Ross A, Hicks A. Management of degloving injuries of the lower extremity: a case report of a forklift injury. Foot Ankle Spec 6:150–153, 2013. 30. Wong LK, Nesbit RD, Turner LA, Sargent LA. Management of a circumferential lower extremity degloving injury with the use of vacuum-assisted closure. South Med J 99:628–630, 2006. 31. Husain ZS, Fallat LM. Maggot therapy for wound debridement in a traumatic footdegloving injury: a case report. J Foot Ankle Surg 42:371–376, 2003.