LACERATION AND DEGLOVING INJURY OF A CHILD'S FOOT – A CASE REPORT


Authors: R. Čáp 1,2;  P. Lochman 1,2;  P. Horyna 2;  J. Koudelka 3;  L. Klein 1,2
Authors‘ workplace: 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 3
Published in: ACTA CHIRURGIAE PLASTICAE, 51, 2, 2009, pp. 45-47

INTRODUCTION

Laceration 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.

CASE REPORT

A four-year-old 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.

During 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).

Fig. 1. Avulsed skin with amputated toes
Fig. 1. Avulsed skin with amputated toes

In 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.

Fig. 2. Fixation of the skin – full-thickness skin graft
Fig. 2. Fixation of the skin – full-thickness skin graft

Regular 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 extremity.

The 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 directions.

At 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.

Fig. 3. One year after the injury – the boy is able to squat down
Fig. 3. One year after the injury – the boy is able to squat down

DISCUSSION

Due 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.

This technique represents relatively fast and simple method, which could be used in this kind of injuries (5).

CONCLUSION

Treatment 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.

Address for correspondence:

Robert Čáp, M.D., Ph.D.
Department of Field Surgery, Faculty of Military Health Sciences
University of Defense Hradec Králové
Třebešská 1575
500 01 Hradec Králové
Czech Republic
E-mail: caprober@seznam.cz


Sources

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.

Labels
Plastic surgery Orthopaedics Burns medicine Traumatology
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