- Email: [email protected]
Sagittal cut injury of the foot at workplace – A rare injury pattern and its management
Accepted Manuscript Title: Sagittal cut injury of the foot at workplace- a rare injury pattern and its management Author: R.H.H. Arjun Vijay Goni Uday Guled Sandeep Patel Rakesh John Prateek Behera PII: DOI: Reference:
S0958-2592(15)00091-7 http://dx.doi.org/doi:10.1016/j.foot.2015.09.006 YFOOT 1407
To appear in:
The Foot
Received date: Revised date: Accepted date:
24-6-2015 9-8-2015 22-9-2015
Please cite this article as: Arjun RHH, Goni V, Guled U, Patel S, John R, Behera P, Sagittal cut injury of the foot at workplace- a rare injury pattern and its management, The Foot (2015), http://dx.doi.org/10.1016/j.foot.2015.09.006 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Highlights
2 3 4 5 6
Various patterns of injuries to foot are described in the literature but the sagittal cut injury of foot with a cut starting from the 3rd toe; then extending between 2nd and 3rd metatarsals, middle and lateral cuneiform; exiting by splitting of calcaneum and talus with a near total traumatic amputation of great toe while handling a machine is yet to be described in the english literature to our knowledge.
7 8
We managed this foot by fixing the fractures and reconstructing the foot. In the follow up there were no complications, wound healed completely and had sensations.
cr
Our aim of salvaging the foot was successful and the patient is now ready to bear weight on it and walk.
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AUTHORS
14
1) ARJUN R.H.H (CORRESPONDING AUTHOR)
15
SENIOR RESIDENT,
16
DEPT OF ORTHOPEDICS
17
PGIMER, CHANDIGARH
18
INDIA.
19
Email: [email protected]
20
Address: 275, O block, NDH, PGIMER, Chandigarh, India
21
2) DR VIJAY GONI
22
ADDITIONAL PROFESSOR,
23
DEPT OF ORTHOPEDICS
24
PGIMER, CHANDIGARH
25
INDIA.
26
3) DR UDAY GULED
27
SENIOR RESIDENT,
28
DEPT OF ORTHOPEDICS
29
PGIMER, CHANDIGARH
30
INDIA
31
4) DR SANDEEP PATEL
32
ASSISTANT PROFESSOR,
33
DEPT OF ORTHOPEDICS
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Sagittal cut injury of the foot at workplace- a rare injury pattern and its management
Page 2 of 10
ESI MEDICAL COLLEGE AND HOSPITAL, BANGALORE
35
INDIA
36
5) DR RAKESH JOHN
37
SENIOR RESIDENT,
38
DEPT OF ORTHOPEDICS
39
PGIMER, CHANDIGARH
40
INDIA
41
6) PRATEEK BEHERA
42
SENIOR RESIDENT,
43
DEPT OF ORTHOPEDICS
44
PGIMER, CHANDIGARH
45
INDIA
48 49
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Abstract
52 53 54 55 56
Extremity injuries to employees in an industrial setting are not an uncommon event in today’s mechanised workspace. Cut injuries of the foot during handling of machines are common in the workplace and the management of such injuries depends upon various factors at the time of presentation. This case report describes a rare foot injury which has not previously been reported in the literature and describes its subsequent successful management.
57
Introduction
58 59 60 61 62 63 64 65
Injuries of foot are commonly encountered in the trauma centre, either in isolation or in association with poly-trauma. Cut injuries to the foot are next only to that of the hand and distal leg in their incidence at the workplace [1]. The mechanism of foot injuries occurring in the workplace are either due to a fall of a heavy object causing a crush injury or sharp cut injuries while handling machines for example [2,3]. Cut injury is mostly due to the foot getting accidentally caught in the sharp moving parts of the machine during improper handling. The treatment options depend upon the severity of injury and the length of time elapsed at the time of presentation.
66 67 68 69 70
Various patterns of foot injuries are described in the currently available literature. This current study describes a large sagittal cut injury involving the entire foot, with the cut emanating at the toe and exiting by splitting of the calcaneum and talus. Such an injury has not previously been reported in the literature. This case report also highlights the treatment options available for this rare injury.
71
Case report
72 73 74
A 40-year-old male patient presented to the trauma centre with a cut injury to his left foot, which got accidentally stuck in the blade of a machine he was operating. The affected foot was splinted at a local hospital and was then referred to the trauma centre for further management.
75 76 77 78 79 80 81 82 83
On examination, there was a large sagittal cut involving the foot, with the cut starting from the 3rd toe, then extending between 2nd-3rd metatarsals, traversing between middle-lateral cuneiforms and then exiting through the calcaneum and talus. Near total amputation of the great toe associated with degloving injury of the foot on both sides was seen. Grossly, it looked as though the foot had been chopped off into two almost symmetrical halves (fig1). There was no active bleeding from the wound. Dorsalis pedis was not palpable, but capillary refilling of all the toes except the great toe was less than two seconds, with sensations and pinprick bleed being intact over the lateral four toes. After cleansing the wound with saline, the patient was moved to the Xray room with a temporary bandage splint, asepsis being maintained at all times. Radiographs of
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Sagittal cut injury of the foot at workplace- a rare injury pattern and its management
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foot and ankle showed near total amputation of the great toe, fractures of the talus, calcaneum, base of the 3rd toe proximal phalanx and metatarsal head, an abnormal gap was noted between 2nd - 3rd metatarsal and middle-lateral cuneiform (fig 2). With the intent of reconstructing the foot and salvaging it, the patient was shifted to the operating theatre.
88 89
Fig 1.(a) Showing sagittal cut injury of the foot into two pieces. (b) Showing near total amputation of great toe, medial and lateral degloving injury of the foot.
90 91 92
Fig 2. (a and b) Antero-posterior and lateral radiographs of the foot showing near total amputation of the great toe, fractures of talus, calcaneum, base of 3rd toe proximal phalanx and metatarsal head.
93 94 95 96 97 98
Thorough debridement and revision amputation of the great toe was done. Both halves of the calcaneum and talus were approximated and fixed with multiple K-wires and small fragment partially threaded cancellous screws. The mid foot was transfixed with multiple threaded Kwires and the 3rd metatarsal head was fixed with a single K-wire. Split skin grafts harvested from the ipsilateral thigh were used to cover the wounds over the medial and lateral sides of the foot (fig 3).
99 100 101
Fig 3. (a and b) Antero-posterior and Lateral radiographs of the foot showing revision amputation of the great toe and fractures fixed with multiple k-wires and small fragment partially threaded cancellous screws.
102 103 104 105 106
Post operatively, there was good capillary refilling of the toes with intact sensations. The wound was observed over the 2nd, 4th and 8th post-operative days, with the graft being healthy; patient was discharged without any complications. At three-month follow up, the wound was healthy with the graft being taken up completely and fractures were uniting with an intact sensation over the salvaged foot (fig 4).
107 108 109
Fig 4. (a and b) Antero-posterior and lateral radiographs of the foot showing good fixation of the fractures at the end of 12 weeks. (c and d) Photographs showing completely healed wound and the healthy graft over the foot.
110
Discussion
111 112 113 114 115 116 117
The foot is the 3rd most commonly involved part in extremity injuries caused by trauma following injuries to the hand and distal leg [1]. Objects causing injuries to the foot may be broadly divided into either sharp or blunt objects. Accidental machine injury to the foot in the work place is a well known injury and described in literature [4,5]. The sagittal cut injury of the foot as described previously is new to the currently available literature and has yet to be reported. The mechanism of injury in this case is not difficult to explain; with the patient’s foot coming under the sharp cutting blade of the machine, splitting the foot sagittally in two. The remaining
Ac ce p
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Page 5 of 10
injuries can be explained by secondary trauma by the blade, as the traumatised patient attempted to pull his leg back.
120 121 122 123 124 125
After necessary investigations and confirmation of findings, the plan was to salvage the limb. Due to paucity of literature regarding management of such a rare case, it was decided to get all the necessary implants required and to follow the surgical steps according to the intra-operative findings. After debridement and wound lavage, bleeding raw surfaces from the fracture fragments was found and fixation of the fragments proceeded. Soft tissue cover was given primarily with split skin graft and the foot was immobilised using a posterior splint.
126 127 128 129 130
In the post-operative period, infection and viability were the main concerns, but the wound responded well to dressings and antibiotics. The foot appeared to be viable with intact vascularity at the time of discharge. At 12 weeks post-operatively, the wound healed completely and the aim of salvaging the foot was successful. Further long-term follow up will reveal the extent of total functionality afforded by the surgery.
131 132
By reporting this case a rare type of foot injury has been described and a possible treatment option for successful outcome has been highlighted.
133
References
134 135 136
1) Bureau of Labor Statistics. Case and demographic characteristics for work-related injury and illness involving days away from work. Washington, DC: Bureau of Labor Statistics, US Departmentof Labor; 1992– 1999.
137
2) National Safety Council. Accident facts, 24. Washington, DC: National Safety Council; 1985.
138 139
3) Copuroglu C, Heybeli N, Ozcan M et al.Major extremity injuries associated with farmyard accidents.ScientificWorldJournal. 2012:314-38.
140 141
4) Voaklander DC, Kelly KD, Rowe BH, et al. Pain, medication, and injury in older farmers. American Journal of Industrial Medicine. 2006;49(5):374–382.
142 143
5) Goldcamp M, Hendricks KJ, Myers JR. Farm fatalities to youth 1995–2000: a comparison by age groups. Journal of Safety Research. 2004;35(2):151–157.
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S0958-2592(15)00091-7 http://dx.doi.org/doi:10.1016/j.foot.2015.09.006 YFOOT 1407
To appear in:
The Foot
Received date: Revised date: Accepted date:
24-6-2015 9-8-2015 22-9-2015
Please cite this article as: Arjun RHH, Goni V, Guled U, Patel S, John R, Behera P, Sagittal cut injury of the foot at workplace- a rare injury pattern and its management, The Foot (2015), http://dx.doi.org/10.1016/j.foot.2015.09.006 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Highlights
2 3 4 5 6
Various patterns of injuries to foot are described in the literature but the sagittal cut injury of foot with a cut starting from the 3rd toe; then extending between 2nd and 3rd metatarsals, middle and lateral cuneiform; exiting by splitting of calcaneum and talus with a near total traumatic amputation of great toe while handling a machine is yet to be described in the english literature to our knowledge.
7 8
We managed this foot by fixing the fractures and reconstructing the foot. In the follow up there were no complications, wound healed completely and had sensations.
cr
Our aim of salvaging the foot was successful and the patient is now ready to bear weight on it and walk.
us
9 10
ip t
1
Ac ce p
te
d
M
an
11
Page 1 of 10
11
13
AUTHORS
14
1) ARJUN R.H.H (CORRESPONDING AUTHOR)
15
SENIOR RESIDENT,
16
DEPT OF ORTHOPEDICS
17
PGIMER, CHANDIGARH
18
INDIA.
19
Email: [email protected]
20
Address: 275, O block, NDH, PGIMER, Chandigarh, India
21
2) DR VIJAY GONI
22
ADDITIONAL PROFESSOR,
23
DEPT OF ORTHOPEDICS
24
PGIMER, CHANDIGARH
25
INDIA.
26
3) DR UDAY GULED
27
SENIOR RESIDENT,
28
DEPT OF ORTHOPEDICS
29
PGIMER, CHANDIGARH
30
INDIA
31
4) DR SANDEEP PATEL
32
ASSISTANT PROFESSOR,
33
DEPT OF ORTHOPEDICS
Ac ce p
te
d
M
an
us
cr
ip t
12
Sagittal cut injury of the foot at workplace- a rare injury pattern and its management
Page 2 of 10
ESI MEDICAL COLLEGE AND HOSPITAL, BANGALORE
35
INDIA
36
5) DR RAKESH JOHN
37
SENIOR RESIDENT,
38
DEPT OF ORTHOPEDICS
39
PGIMER, CHANDIGARH
40
INDIA
41
6) PRATEEK BEHERA
42
SENIOR RESIDENT,
43
DEPT OF ORTHOPEDICS
44
PGIMER, CHANDIGARH
45
INDIA
48 49
cr us an M d
te
47
Ac ce p
46
ip t
34
Page 3 of 10
49
51
Abstract
52 53 54 55 56
Extremity injuries to employees in an industrial setting are not an uncommon event in today’s mechanised workspace. Cut injuries of the foot during handling of machines are common in the workplace and the management of such injuries depends upon various factors at the time of presentation. This case report describes a rare foot injury which has not previously been reported in the literature and describes its subsequent successful management.
57
Introduction
58 59 60 61 62 63 64 65
Injuries of foot are commonly encountered in the trauma centre, either in isolation or in association with poly-trauma. Cut injuries to the foot are next only to that of the hand and distal leg in their incidence at the workplace [1]. The mechanism of foot injuries occurring in the workplace are either due to a fall of a heavy object causing a crush injury or sharp cut injuries while handling machines for example [2,3]. Cut injury is mostly due to the foot getting accidentally caught in the sharp moving parts of the machine during improper handling. The treatment options depend upon the severity of injury and the length of time elapsed at the time of presentation.
66 67 68 69 70
Various patterns of foot injuries are described in the currently available literature. This current study describes a large sagittal cut injury involving the entire foot, with the cut emanating at the toe and exiting by splitting of the calcaneum and talus. Such an injury has not previously been reported in the literature. This case report also highlights the treatment options available for this rare injury.
71
Case report
72 73 74
A 40-year-old male patient presented to the trauma centre with a cut injury to his left foot, which got accidentally stuck in the blade of a machine he was operating. The affected foot was splinted at a local hospital and was then referred to the trauma centre for further management.
75 76 77 78 79 80 81 82 83
On examination, there was a large sagittal cut involving the foot, with the cut starting from the 3rd toe, then extending between 2nd-3rd metatarsals, traversing between middle-lateral cuneiforms and then exiting through the calcaneum and talus. Near total amputation of the great toe associated with degloving injury of the foot on both sides was seen. Grossly, it looked as though the foot had been chopped off into two almost symmetrical halves (fig1). There was no active bleeding from the wound. Dorsalis pedis was not palpable, but capillary refilling of all the toes except the great toe was less than two seconds, with sensations and pinprick bleed being intact over the lateral four toes. After cleansing the wound with saline, the patient was moved to the Xray room with a temporary bandage splint, asepsis being maintained at all times. Radiographs of
Ac ce p
te
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M
an
us
cr
ip t
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Sagittal cut injury of the foot at workplace- a rare injury pattern and its management
Page 4 of 10
foot and ankle showed near total amputation of the great toe, fractures of the talus, calcaneum, base of the 3rd toe proximal phalanx and metatarsal head, an abnormal gap was noted between 2nd - 3rd metatarsal and middle-lateral cuneiform (fig 2). With the intent of reconstructing the foot and salvaging it, the patient was shifted to the operating theatre.
88 89
Fig 1.(a) Showing sagittal cut injury of the foot into two pieces. (b) Showing near total amputation of great toe, medial and lateral degloving injury of the foot.
90 91 92
Fig 2. (a and b) Antero-posterior and lateral radiographs of the foot showing near total amputation of the great toe, fractures of talus, calcaneum, base of 3rd toe proximal phalanx and metatarsal head.
93 94 95 96 97 98
Thorough debridement and revision amputation of the great toe was done. Both halves of the calcaneum and talus were approximated and fixed with multiple K-wires and small fragment partially threaded cancellous screws. The mid foot was transfixed with multiple threaded Kwires and the 3rd metatarsal head was fixed with a single K-wire. Split skin grafts harvested from the ipsilateral thigh were used to cover the wounds over the medial and lateral sides of the foot (fig 3).
99 100 101
Fig 3. (a and b) Antero-posterior and Lateral radiographs of the foot showing revision amputation of the great toe and fractures fixed with multiple k-wires and small fragment partially threaded cancellous screws.
102 103 104 105 106
Post operatively, there was good capillary refilling of the toes with intact sensations. The wound was observed over the 2nd, 4th and 8th post-operative days, with the graft being healthy; patient was discharged without any complications. At three-month follow up, the wound was healthy with the graft being taken up completely and fractures were uniting with an intact sensation over the salvaged foot (fig 4).
107 108 109
Fig 4. (a and b) Antero-posterior and lateral radiographs of the foot showing good fixation of the fractures at the end of 12 weeks. (c and d) Photographs showing completely healed wound and the healthy graft over the foot.
110
Discussion
111 112 113 114 115 116 117
The foot is the 3rd most commonly involved part in extremity injuries caused by trauma following injuries to the hand and distal leg [1]. Objects causing injuries to the foot may be broadly divided into either sharp or blunt objects. Accidental machine injury to the foot in the work place is a well known injury and described in literature [4,5]. The sagittal cut injury of the foot as described previously is new to the currently available literature and has yet to be reported. The mechanism of injury in this case is not difficult to explain; with the patient’s foot coming under the sharp cutting blade of the machine, splitting the foot sagittally in two. The remaining
Ac ce p
te
d
M
an
us
cr
ip t
84 85 86 87
Page 5 of 10
injuries can be explained by secondary trauma by the blade, as the traumatised patient attempted to pull his leg back.
120 121 122 123 124 125
After necessary investigations and confirmation of findings, the plan was to salvage the limb. Due to paucity of literature regarding management of such a rare case, it was decided to get all the necessary implants required and to follow the surgical steps according to the intra-operative findings. After debridement and wound lavage, bleeding raw surfaces from the fracture fragments was found and fixation of the fragments proceeded. Soft tissue cover was given primarily with split skin graft and the foot was immobilised using a posterior splint.
126 127 128 129 130
In the post-operative period, infection and viability were the main concerns, but the wound responded well to dressings and antibiotics. The foot appeared to be viable with intact vascularity at the time of discharge. At 12 weeks post-operatively, the wound healed completely and the aim of salvaging the foot was successful. Further long-term follow up will reveal the extent of total functionality afforded by the surgery.
131 132
By reporting this case a rare type of foot injury has been described and a possible treatment option for successful outcome has been highlighted.
133
References
134 135 136
1) Bureau of Labor Statistics. Case and demographic characteristics for work-related injury and illness involving days away from work. Washington, DC: Bureau of Labor Statistics, US Departmentof Labor; 1992– 1999.
137
2) National Safety Council. Accident facts, 24. Washington, DC: National Safety Council; 1985.
138 139
3) Copuroglu C, Heybeli N, Ozcan M et al.Major extremity injuries associated with farmyard accidents.ScientificWorldJournal. 2012:314-38.
140 141
4) Voaklander DC, Kelly KD, Rowe BH, et al. Pain, medication, and injury in older farmers. American Journal of Industrial Medicine. 2006;49(5):374–382.
142 143
5) Goldcamp M, Hendricks KJ, Myers JR. Farm fatalities to youth 1995–2000: a comparison by age groups. Journal of Safety Research. 2004;35(2):151–157.
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