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The landmine foot: its description and management
Injury (1991) 22, (6), 463-466
Printed in Great Britain
463
The landmine foot: its description and management L. G. H. Jacobs Oshakati
State Hospital, Oshakati, Owambo,
Namibia
The irliuriesof 54 patients involved in landmine explosions are described. In 72 per cent the injuries affected the mid- and hindfaof. Oi these injctries, 67 per cent were open fractures involving the calcaneus. 7he injuy resulted in the ‘lam&nine foot’, an entity not previously described. Its clinical features and ortkotic management are described. The prognosis of ‘Iandmine foot’ was generally favourable in this Third World setting, with adequate rehabilitation provided by a customized surgical boot.
Introduction The ability to walk is an important means of obtaining a livelihood and as a mode of travel for all Owambos who live in the north of Namibia, in an area twice the size of Wales. This part of Namibia was the centre of a guerilla war, which until recently has largely involved the civilian population. Oshakati Hospital is a so&bed state hospital situated in the middle of Owamboland, 5Okm south of the border with Angola. It serves as the main referral hospital, with adequate basic medical facilities for the estimated 500 000 inhabitants. Bristow (1943) first stated that fractures of the calcaneus were common in wartime, and Harris (1946) noted that these injuries were characterized by extensive comminution. Trueta (1944a, b) established the principles of the management of wartime fractures, especially with regard to open fractures. King (1969) highlighted the difference in the pattern of injury between the bare and the shod foot when exposed to the blast of a landinine. He noted that the latter had a much better chance of withstanding the blast. This report describes the clinical features of the ‘landmine foot’, with particular emphasis on the orthotic rehabilitation of such patients’ feet in a Third World setting.
Case series Patients injured in landmine explosions who presented between 1978 and 1980 to Oshakati Hospital form the basis of this report. All were civilian Owambos who were injured while travelling on unprotected pick-up type motor vehicles. All wore shoes and were standing upright at the time of the explosion. On arrival at hospital they were resuscitated and their injuries were assessed. Open injuries were managed according to Trueta (1944a). When performing the primary wound excision special consideration was given to the following: 1. Cordite impregnation was removed a potent promoter of sepsis. 1s 1991 Butterworth-Heinemann 0020-1383/91/060463-04
Ltd
as far as possible as it is
2. Cognizance was taken of blast dissection along tissue planes leaving foreign bodies and bony debris in deep, potentially septic tracts. 3. Open fractures (Custillo types 1 and 2) were treated according to Trueta’s (I944b) principles with plaster splintage. Type 3A and 3B fractures were managed with an external fixator constructed from Steinman pins and bone cement until soft tissue cover was obtained. Only type 3C open fractures underwent amputation. Patients needed secondary procedures at regular intervals. Patients with calcaneal fractures were kept non-weight bearing for 8-12 weeks. Mobilization was slower in severe calcaneal fractures, bilateral injuries, or if a calcaneal fracture was associated with a contralateral amputation. Once the limb was felt to be stable, the patient was assessed at an orthotic clinic, where made-to-measure surgical footwear was prescribed when indicated. A follow-up appointment was arranged 3 months after the footwear had been supplied. Because of the war it was not possible to arrange regular follow-up, for geographical reasons. Patients only returned when their boots required repair or replacement.
Results There were 57 patients, of whom three died within 24 h of reaching hospital due to severe respiratory bums. The 54 survivors consisted of 39 males and 15 females (age range: 5-70 years with 70 per cent in the 20-40 year age group). Hospital stay was prolonged (range 4-453 days, median 100 days) due to a variety of factors, including the geographical situation and the ongoing guerilla war. The anatomical sites of the injuries are shown in TableI. There were nine cases of proven wound sepsis in patients with open fractures of the distal lower leg, ankle and foot. These were superficial and none led to chronic osteomyelitis. There were no cases of tetanus, but one case of clinical gas gangrene that was never proven bacteriologically. Figure I shows typical bilateral open fractures of the hindfeet and Figure 2 shows the radiological appearances of the right foot. The range of orthopaedic appliances supplied is shown in Table II. The unique feature seen in 18 patients (67 per cent of those requiring orthopaedic appliances) was the so-called ‘landmine foot’ (vide infra). For these cases 21 bespoke surgical boots (‘landmine boots’) were supplied. After some initial adjustments, these were all accepted and the patients were able to walk satisfactorily. No patient was registered as disabled for employment and all were discharged home.
Injury: the British Journal of Accident Surgery (1991) Vol. 22/No.
464
Table I. The anatomical regions damaged in survivors of land-
mine explosions Number of injuries
Number of patients injured
15
13
51
40
35 15 6 13 2 18
32 13 6 13 2 10
Forefoot Mid and hindfoot (including malleoli) Tibia and fibula (supramalleolar to knee) Femur Spine Upper limb Pelvis Chest, head and neck
Table II. Prostheses supplied to the 54 survivors Number of patients
%
Unilateral LMB Bilateral LMB LMB and BK prosthesis Unilateral BK prosthesis AK and BK prosthesis Normal footwear No follow-up
9 3 6 7 2 24 3
17 6 11 13 4 44 5
Total
54
Prostheses
LMB: landmine boot. BK: below-knee.
Figure 1. Bilateral open hindfoot
Table III. Outcome patients
6
of the 5 I calcaneal fractures in this group of
Description
Closed/ open
No. of injuries
Calcaneal fracture only
Closed Open
17 2
Normal footwear, no mobilization problems
1
Calcaneal fracture with talar/navicular and/or midtarsal fractures
Closed Open
1 5
Four patients required landmine boots
2
Type 2 fractures associated with malleolar and/or lower leg fractures
Closed Open
4 13
All required landmine boots
3
Totally disrupted foot and lower leg
Open
All amputated
4
of the right hindfoot
open
9
Outcome
Type
AK: above-knee.
fractures.
Discussion A clinical classification of the calcaneal fractures and their associated injuries is shown in TnbleIII This was used in order to prognosticate with regard to the lower limb injuries that a patient had sustained. The ‘landmine foot’ deformity, not previously described in the literature, shows: 1. Patchy pigmentation of the sole of the foot (Figure 3). 2. Full-thickness scars involving the sole which are not usually tender and may extend either medially or laterally (Figure 4). 3. Distortion of the normal anatomy of the plantar fat pads.
Figure 2. Radiological
appearance
fracture.
4. Fibrosis of the intrinsic muscles of the foot and of the long toe flexor tendons. This caused claw toe deformity which, if not checked, could lead to painful toe tip callosities. Due to associated limits of extension of the metatarsophalangeal joint, the walk-over ability of the foot was reduced. 5. Adequate circulation with good protective skin sensation. No trophic ulcers were seen in any patient.
Jacobs: The landmine foot
465
Figure 5. Flat foot deformity
Figure 3. Landmine feet showing the patchy pigmentation soles.
of the landmine foot.
of the
Figure 6. The radiological foot.
appearance
of the healed landmine
arches of the foot. These led to a stiff flat foot deformity (Figures 5, 6), which was especially troublesome because of the uneven walking surface which was the norm in this part of the world. Our approach to this blast injury of the foot was threefold. 1. Surgical
The only surgical procedure performed was fo trim bony prominences on the sole of the foot to improve the contour of its weight-bearing surface. No Dwyer or other wedge osteotomies of the ankylosed talocalcaneal unit were required. Disrupted ankles and feet seemed to require no formal arthrodesis as they developed post-traumatic ankylosis. 2. Physiotherapy This was started as early as possible. Active and passive extension of the toes was encouraged to promote mobility of the metatarsophalangeal joints. The aim was to prevent equinus deformities and stiff toes as far as possible, as these in combination resulted in toe tip and peri-ungal callosities, making walking very difficult. Figure 4. Left landmine scar.
foot with a large full-thickness
medial
of the normal bone and joint anatomy which affected the calcaneus and was associated with subtalar joint ankylosis, fractures of the talus and navicular, obliterated longitudinal and transverse
6. Disruption
3. Orthotic This ‘landmine boot’ (Figure 7) is a bespoke leather boot made by a skilled cobbler from a plaster cast of the patient’s foot. Leather stiffening was added around the proximal part of the boot from the level of the metatarsal heads fo that of the tibiotalar joint. Thus by preventing movement of any disrupted joints, pain was diminished. Latterly, this stiffening was made separately and fitted to the foot over a
466
Injury: the British Journal of Accident Surgery (1991) Vol. 22/No.
6
Acknowledgements I would
like to thank Dr 0. W. van Niekerk, Medical Superintendent, Oshakati State Hospital, for permission to study this group of patients. I would also like to thank Dr J. C. S. Steytler, Consultant in Rehabilitation Medicine, Tygerberg Hospital, Cape Town, Republic of South Africa and Professor W. A. Wallace, Department of Orthopaedic and Accident Surgery, Queen’s Medical Centre, Nottingham, for their advice and help in the preparation of this paper.
Figure 7. The ‘landmine boot’.
sock. The boot extended 5-7 cm proximal to the tibiotalar joint to provide further support and had a tongue which was ‘open to toe’, A rocker sole was added to aid walk-over for the stiff foot. This was centred over the mid-point of the foot between the anterior tibiotalar joint margin and the metatarsal heads distally. A splay or wedge was added to the heel to accommodate a valgus or varus hindfoot deformity.
Conclusion In conclusion I felt that the landmine boot contributed significantly to the rehabilitation of a large number of patients in this group who had a ‘landmine foot’ deformity. The degree of mobility achieved was satisfactory and adequate to cope with their environment and occupations. However, the manufacture of this high-quality footwear would not have been possible without the skills of the orthotists and bootmakers involved, and the government funding made available for this service.
References Bristow W. R. (1943) Some surgical lessons of the war. J. Bone Joint Sq. 25, 524. Harris R. I. (1946) Fractures of the OS calcis. Ann. Surg. 124, 1082. King K. F. (1969) Orthopaedic aspects of war wounds in South Vietnam. J. Bone Joint Sttrg. 5 IB, 112. Trueta J. (ed) (1944a) Wound excision. In: The Pri’nciplesand Pructice of War Surgery, 2nd Ed. London: Hamilton and Heinemann Medical Books Ltd, 188. Trueta J. (ed) (1944b) Immobilisation. In: The Principles and Practice of War Surgery, 2nd Ed. London: Hamilton and Heinemann Medical Books Ltd, 215.
Paper accepted 8 April 1991.
Reqcreslsfor reprints should be &dressed to: Mr L. G. H. Jacobs, Senior Registrar, Dept. Orthopaedic Surgery, Clinical Sciences Building, Hope Hospital, Old Eccles Road, Salford, Manchester M6 BHD, UK.
Printed in Great Britain
463
The landmine foot: its description and management L. G. H. Jacobs Oshakati
State Hospital, Oshakati, Owambo,
Namibia
The irliuriesof 54 patients involved in landmine explosions are described. In 72 per cent the injuries affected the mid- and hindfaof. Oi these injctries, 67 per cent were open fractures involving the calcaneus. 7he injuy resulted in the ‘lam&nine foot’, an entity not previously described. Its clinical features and ortkotic management are described. The prognosis of ‘Iandmine foot’ was generally favourable in this Third World setting, with adequate rehabilitation provided by a customized surgical boot.
Introduction The ability to walk is an important means of obtaining a livelihood and as a mode of travel for all Owambos who live in the north of Namibia, in an area twice the size of Wales. This part of Namibia was the centre of a guerilla war, which until recently has largely involved the civilian population. Oshakati Hospital is a so&bed state hospital situated in the middle of Owamboland, 5Okm south of the border with Angola. It serves as the main referral hospital, with adequate basic medical facilities for the estimated 500 000 inhabitants. Bristow (1943) first stated that fractures of the calcaneus were common in wartime, and Harris (1946) noted that these injuries were characterized by extensive comminution. Trueta (1944a, b) established the principles of the management of wartime fractures, especially with regard to open fractures. King (1969) highlighted the difference in the pattern of injury between the bare and the shod foot when exposed to the blast of a landinine. He noted that the latter had a much better chance of withstanding the blast. This report describes the clinical features of the ‘landmine foot’, with particular emphasis on the orthotic rehabilitation of such patients’ feet in a Third World setting.
Case series Patients injured in landmine explosions who presented between 1978 and 1980 to Oshakati Hospital form the basis of this report. All were civilian Owambos who were injured while travelling on unprotected pick-up type motor vehicles. All wore shoes and were standing upright at the time of the explosion. On arrival at hospital they were resuscitated and their injuries were assessed. Open injuries were managed according to Trueta (1944a). When performing the primary wound excision special consideration was given to the following: 1. Cordite impregnation was removed a potent promoter of sepsis. 1s 1991 Butterworth-Heinemann 0020-1383/91/060463-04
Ltd
as far as possible as it is
2. Cognizance was taken of blast dissection along tissue planes leaving foreign bodies and bony debris in deep, potentially septic tracts. 3. Open fractures (Custillo types 1 and 2) were treated according to Trueta’s (I944b) principles with plaster splintage. Type 3A and 3B fractures were managed with an external fixator constructed from Steinman pins and bone cement until soft tissue cover was obtained. Only type 3C open fractures underwent amputation. Patients needed secondary procedures at regular intervals. Patients with calcaneal fractures were kept non-weight bearing for 8-12 weeks. Mobilization was slower in severe calcaneal fractures, bilateral injuries, or if a calcaneal fracture was associated with a contralateral amputation. Once the limb was felt to be stable, the patient was assessed at an orthotic clinic, where made-to-measure surgical footwear was prescribed when indicated. A follow-up appointment was arranged 3 months after the footwear had been supplied. Because of the war it was not possible to arrange regular follow-up, for geographical reasons. Patients only returned when their boots required repair or replacement.
Results There were 57 patients, of whom three died within 24 h of reaching hospital due to severe respiratory bums. The 54 survivors consisted of 39 males and 15 females (age range: 5-70 years with 70 per cent in the 20-40 year age group). Hospital stay was prolonged (range 4-453 days, median 100 days) due to a variety of factors, including the geographical situation and the ongoing guerilla war. The anatomical sites of the injuries are shown in TableI. There were nine cases of proven wound sepsis in patients with open fractures of the distal lower leg, ankle and foot. These were superficial and none led to chronic osteomyelitis. There were no cases of tetanus, but one case of clinical gas gangrene that was never proven bacteriologically. Figure I shows typical bilateral open fractures of the hindfeet and Figure 2 shows the radiological appearances of the right foot. The range of orthopaedic appliances supplied is shown in Table II. The unique feature seen in 18 patients (67 per cent of those requiring orthopaedic appliances) was the so-called ‘landmine foot’ (vide infra). For these cases 21 bespoke surgical boots (‘landmine boots’) were supplied. After some initial adjustments, these were all accepted and the patients were able to walk satisfactorily. No patient was registered as disabled for employment and all were discharged home.
Injury: the British Journal of Accident Surgery (1991) Vol. 22/No.
464
Table I. The anatomical regions damaged in survivors of land-
mine explosions Number of injuries
Number of patients injured
15
13
51
40
35 15 6 13 2 18
32 13 6 13 2 10
Forefoot Mid and hindfoot (including malleoli) Tibia and fibula (supramalleolar to knee) Femur Spine Upper limb Pelvis Chest, head and neck
Table II. Prostheses supplied to the 54 survivors Number of patients
%
Unilateral LMB Bilateral LMB LMB and BK prosthesis Unilateral BK prosthesis AK and BK prosthesis Normal footwear No follow-up
9 3 6 7 2 24 3
17 6 11 13 4 44 5
Total
54
Prostheses
LMB: landmine boot. BK: below-knee.
Figure 1. Bilateral open hindfoot
Table III. Outcome patients
6
of the 5 I calcaneal fractures in this group of
Description
Closed/ open
No. of injuries
Calcaneal fracture only
Closed Open
17 2
Normal footwear, no mobilization problems
1
Calcaneal fracture with talar/navicular and/or midtarsal fractures
Closed Open
1 5
Four patients required landmine boots
2
Type 2 fractures associated with malleolar and/or lower leg fractures
Closed Open
4 13
All required landmine boots
3
Totally disrupted foot and lower leg
Open
All amputated
4
of the right hindfoot
open
9
Outcome
Type
AK: above-knee.
fractures.
Discussion A clinical classification of the calcaneal fractures and their associated injuries is shown in TnbleIII This was used in order to prognosticate with regard to the lower limb injuries that a patient had sustained. The ‘landmine foot’ deformity, not previously described in the literature, shows: 1. Patchy pigmentation of the sole of the foot (Figure 3). 2. Full-thickness scars involving the sole which are not usually tender and may extend either medially or laterally (Figure 4). 3. Distortion of the normal anatomy of the plantar fat pads.
Figure 2. Radiological
appearance
fracture.
4. Fibrosis of the intrinsic muscles of the foot and of the long toe flexor tendons. This caused claw toe deformity which, if not checked, could lead to painful toe tip callosities. Due to associated limits of extension of the metatarsophalangeal joint, the walk-over ability of the foot was reduced. 5. Adequate circulation with good protective skin sensation. No trophic ulcers were seen in any patient.
Jacobs: The landmine foot
465
Figure 5. Flat foot deformity
Figure 3. Landmine feet showing the patchy pigmentation soles.
of the landmine foot.
of the
Figure 6. The radiological foot.
appearance
of the healed landmine
arches of the foot. These led to a stiff flat foot deformity (Figures 5, 6), which was especially troublesome because of the uneven walking surface which was the norm in this part of the world. Our approach to this blast injury of the foot was threefold. 1. Surgical
The only surgical procedure performed was fo trim bony prominences on the sole of the foot to improve the contour of its weight-bearing surface. No Dwyer or other wedge osteotomies of the ankylosed talocalcaneal unit were required. Disrupted ankles and feet seemed to require no formal arthrodesis as they developed post-traumatic ankylosis. 2. Physiotherapy This was started as early as possible. Active and passive extension of the toes was encouraged to promote mobility of the metatarsophalangeal joints. The aim was to prevent equinus deformities and stiff toes as far as possible, as these in combination resulted in toe tip and peri-ungal callosities, making walking very difficult. Figure 4. Left landmine scar.
foot with a large full-thickness
medial
of the normal bone and joint anatomy which affected the calcaneus and was associated with subtalar joint ankylosis, fractures of the talus and navicular, obliterated longitudinal and transverse
6. Disruption
3. Orthotic This ‘landmine boot’ (Figure 7) is a bespoke leather boot made by a skilled cobbler from a plaster cast of the patient’s foot. Leather stiffening was added around the proximal part of the boot from the level of the metatarsal heads fo that of the tibiotalar joint. Thus by preventing movement of any disrupted joints, pain was diminished. Latterly, this stiffening was made separately and fitted to the foot over a
466
Injury: the British Journal of Accident Surgery (1991) Vol. 22/No.
6
Acknowledgements I would
like to thank Dr 0. W. van Niekerk, Medical Superintendent, Oshakati State Hospital, for permission to study this group of patients. I would also like to thank Dr J. C. S. Steytler, Consultant in Rehabilitation Medicine, Tygerberg Hospital, Cape Town, Republic of South Africa and Professor W. A. Wallace, Department of Orthopaedic and Accident Surgery, Queen’s Medical Centre, Nottingham, for their advice and help in the preparation of this paper.
Figure 7. The ‘landmine boot’.
sock. The boot extended 5-7 cm proximal to the tibiotalar joint to provide further support and had a tongue which was ‘open to toe’, A rocker sole was added to aid walk-over for the stiff foot. This was centred over the mid-point of the foot between the anterior tibiotalar joint margin and the metatarsal heads distally. A splay or wedge was added to the heel to accommodate a valgus or varus hindfoot deformity.
Conclusion In conclusion I felt that the landmine boot contributed significantly to the rehabilitation of a large number of patients in this group who had a ‘landmine foot’ deformity. The degree of mobility achieved was satisfactory and adequate to cope with their environment and occupations. However, the manufacture of this high-quality footwear would not have been possible without the skills of the orthotists and bootmakers involved, and the government funding made available for this service.
References Bristow W. R. (1943) Some surgical lessons of the war. J. Bone Joint Sq. 25, 524. Harris R. I. (1946) Fractures of the OS calcis. Ann. Surg. 124, 1082. King K. F. (1969) Orthopaedic aspects of war wounds in South Vietnam. J. Bone Joint Sttrg. 5 IB, 112. Trueta J. (ed) (1944a) Wound excision. In: The Pri’nciplesand Pructice of War Surgery, 2nd Ed. London: Hamilton and Heinemann Medical Books Ltd, 188. Trueta J. (ed) (1944b) Immobilisation. In: The Principles and Practice of War Surgery, 2nd Ed. London: Hamilton and Heinemann Medical Books Ltd, 215.
Paper accepted 8 April 1991.
Reqcreslsfor reprints should be &dressed to: Mr L. G. H. Jacobs, Senior Registrar, Dept. Orthopaedic Surgery, Clinical Sciences Building, Hope Hospital, Old Eccles Road, Salford, Manchester M6 BHD, UK.