R. Čáp 1,2; P. Lochman 1,2; P. Horyna 2; J. Koudelka 3; L. Klein 1,2
Department of Field Surgery, Faculty of Military Health Sciences, University of Defense, Hradec Králové
1; Department of Surgery, University Hospital, Hradec Králové, and
2; Department of Pediatric Surgery, University Hospital, Hradec Králové, Czech Republic
ACTA CHIRURGIAE PLASTICAE, 51, 2, 2009, pp. 45-47
and degloving injury to a child’s foot is quite a rare
occurence. Traffic injuries are the commonest cause in children, but
some others such as escalator-related injuries have been published as
well (1). Treatment options for such an injury depend on the specific
type of injury and the customary practice of each surgical
department. In our case, after assesment of soft tissue and bones of
the right foot we decided on the simplest possible method – to
perform osteosynthesis by Kirschner wires and then to use
a full-thickness skin graft.
boy was referred to our emergency department with injury to his right
foot caused by a collision with a truck. While admitted he
was conscious and haemodynamically stable. He was completely examined
and was found to have a laceration and degloving injury to his
right foot, without any other trauma. Abdominal and thoracic
ultrasound examination was negative. Chest, pelvic and the right shin
X-rays were negative. An X-ray of the right foot was not transparent.
Hemoglobin level was 81 g/l, hematocrit was 0.232. Active and passive
prophylaxis of tetanus was given to the patient. After necessary
preparation the patient was transported from the emergency room to
the operating theatre.
the revision under general anesthesia we found the following
injuries: degloving injury of the right foot from the ankle distally;
connection of the avulsed skin with the foot was only 1 cm wide;
apex of avulsed tissue with amputation of first, fourth and fifth
toe; fracture of the first metatarsal bone; amputation of the second
toe in the diaphysis of the second metatarsal bone (Fig. 1).
the operating theatre we ensured careful haemostasis. Then we carried
out ostheosynthesis of the first metatarsal bone
with two Kirschner wires and debridement of the soft tissue. We then
used the remaining soft tissue to partially cover
the exposed metatarsal bones. We performed defatting
and thinning of the skin of the foot, which was avulsed
together with subcutaneous tissue. The skin was then fixed round the
foot and the stumps of the digits as a full-thickness graft
(Fig. 2). The graft was handled in the usual manner. The right foot
was fixed in a plaster splint. The patient was given
a combination of antibiotics: amoxicilin, gentamicin,
lincosamin, and erythrocyte concentrate because of the anemia.
wound bandage changes were provided three times a week under
general anesthesia; altogether twenty wound bandage changes were
performed. Unfortunately, after 14 days we observed small areas of
necrotic tissue on the external wedge and proximal part of the
instep. Small necrectomies had to be performed, and one week later –
after wound bed preparation – we covered these defects using
a dermoepidermal skin graft taken from the lateral side of the
right thigh. Following this procedure healing of both the
transplanted skin mesh and donor site was uneventful. The patient was
released from hospital on the 47th
postoperative day. The Kirschner wires from the first metatarsal bone
were then extracted on the 51stpostoperative day in the outpatient department.
The plaster splint was removed on the 61st postoperative day and rehabilitation was begun.
One month after that, the boy began to stand on the right lower
boy went through two spa treatments (each lasting one month) because
of rehabilitation of the right ankle, to improve the strength of the
muscles of the right lower extremity, and to practice standing and
walking behavior. Seven months after the injury the boy was able to
walk and run freely; movement of the right ankle was possible in all
1-year follow-up we could see excellent functional and cosmetic
effect. The boy needed no orthotics and was able to squat down (Fig.
3), to stand on the affected foot and walk on tiptoe. He was fully
included in society of children of the same age. At nearly 2-year
follow-up we can observe a stable situation, though the
sensitivity of the reattached skin is a little diminished;
however, there are no ulcers on the bearing area of the sole.
to the relatively low incidence of this kind of injury there are only
few references related to this topic, especially in children. Several
methods have been described previously in management of degloving
injuries, including microvascular free flap, local flap or skin graft
(2, 3). Simply reattaching the avulsed flap by suturing it back into
its bed may result in ischemic necrosis, especially in adults (4). In
children, necrotic changes are seen less frequently, perhaps due to
relatively lower bearing area and total weight. In our case report we
present the simplest possible method of treatment of such injuries:
careful thinning and deffating of the avulsed flap and reattachment
as a full-thickness skin graft. In this case there were no
serious complications during healing, the only minor complication was
that small districts of necrotic tissue of the original skin graft
had to be excised. The defects were covered with dermoepidermal mesh
graft taken from the right thigh with satisfactory effect.
technique represents relatively fast and simple method, which could
be used in this kind of injuries (5).
of degloving injuries in children can be successfully managed by
using a defatted full-thickness skin graft. This procedure is
relatively easy to perform and therefore need not be reserved for
plastic surgeons. Very good functional and aesthetic results can be
achieved, as with the case we present.
Čáp, M.D., Ph.D. Department
of Field Surgery, Faculty of Military Health Sciences University
of Defense Hradec Králové Třebešská
01 Hradec Králové Czech
1. Platt SL., Fine JS., Foltin GL. Escalator-related injuries in children. Pediatrics, 100, 1997, e2. doi: 10.1542/peds.100.2.e2.
2. Lickstein L., Bentz M. Reconstruction of pediatric foot and ankle trauma. J. Craniofac. Surg., 14, 2003, p. 559-565.
3. Zgonis T., Cromack DT., Roukis TS., Orphanos J., Polyzois,VD. Severe degloving injury of the sole and heel treated by a reverse flow sural artery neurofasciocutaneous flap and a modified off-loading external fixation device. Injury Extra, 38, 2007, p. 187-192.
4. Huemer GM., Schoeller T., Dunst,KM., Rainer C. Management of traumatically avulsed skin-flap on the dorsum of the foot. Arch. Orthop. Trauma Surg., 124, 2004, p. 559-562.
5. Waikakul S. Revascularisation of degloving injuries of the limbs. Injury, 28, 1997, p. 271-274.