Split-thickness skin excision: its use for immediate wound care in crush injuries of the foot

The Innervated Distally Based First Dorsal Metatarsal Artery Flap with a Wide Pedicle for Reconstruction of a Great Toe Defect

Background

It is difficult for surgeons to reconstruct soft tissue defects of the great toe. This report aims to evaluate the utility and efficacy of innervated distally based first dorsal metatarsal artery (FDMA) flap with a wide pedicle for reconstruction of soft tissue defects of the great toe.

Methods

This is a retrospective report. Between January 2015 and December 2017, six cases of skin defect of the great toe were reconstructed with an innervated distally based FDMA flap with a wide pedicle. One case was excluded in this report because of chronic pain on the metatarsophalangeal joint due to osteoarthritis before the injury. A total of five cases were evaluated for flap survival and sensory recovery. The sensory recovery was investigated by two-point discrimination and Semmes-Weinstein monofilament tests. The average age of the selected patients was 40 years (range, 36 to 56 years), and the average size of the defect in the toe was 8.3 cm² (range, 4 to 13.8 cm²). The average follow-up period was 29.4 months (range, 18 to 38 months).

Results

All patients survived without any complications. The average two-point discrimination test value was 8.0 ± 0.89 mm (range, 7 to 9 mm), and the average value obtained from the Semmes-Weinstein monofilament test was 4.53 ± 0.33 (range, 4.17 to 4.93). The average residual pain score evaluated with a visual analog scale was 1 (range, 0 to 2). Two patients complained of stiffness in the great toe below 30° of total range of motion during the early stages after surgery, but this stiffness gradually improved after rehabilitation. The average range of motion of three patients with a remaining metatarsophalangeal joint after surgery was 80° (range, 70° to 90°). All five cases could walk regularly without any unique footwear at the final follow-up.

Conclusions

The innervated distally based FDMA flap with a wide pedicle could be a good alternative method for repair of soft tissue defects of the great toe.

The role of plastic surgery for soft tissue coverage of the diabetic foot and ankle

The goal of wound healing is to obtain the best closure through the least morbid means. In the surgical treatment of the diabetic foot and ankle, the reconstructive foot and ankle surgeon is tasked with the challenge of repairing a variety of tissue defects. The decision for wound closure depends on the location of the wound and host factors. In order of increasing complexity, the clinician should consider the reconstruction decision ladder algorithm. Wound evaluation coupled with the knowledge of various closure techniques and their indications will arm the surgeon with the tools for a successful closure.

Injury to the tarsometatarsal joint complex

Tarsometatarsal joint complex fracture-dislocations may result from direct or indirect trauma. Direct injuries are usually the result of a crush and may involve associated compartment syndrome, significant soft-tissue injury, and open fracture-dislocation. Indirect injuries are often the result of an axial load to the plantarflexed foot. Midfoot pain after even a minor forefoot injury should raise suspicion; up to 20% of tarsometatarsal joint complex injuries are missed on initial examination. An anteroposterior radiograph with abduction stress may reveal subtle injury, but computed tomography is the preferred imaging modality. The goal of treatment is the restoration of a pain-free, functional foot. The preferred treatment is open reduction and internal fixation, using screw fixation for the medial three rays and Kirschner wires for the fourth and fifth tarsometatarsal joints. Satisfactory outcome can be expected in approximately 90% of patients.

Crush injuries of the foot in the industrial setting

Over the years patients with relatively minor compressive injuries seem to have a different morbidity, largely because of a constellation of neurologic findings, including dysesthesia and hyperesthesias. These are usually multifocal, and often extend far beyond the point of impact of the crushing force. Neuroischemia may play a role in the development of chronic pain after crush injuries to the foot, either through direct trauma to the peripheral nerves or by intraneural or extraneural fibrosis. This direct trauma to the nerve may cause chronic neuritis, which then triggers a sympathetically mediated pain syndrome. For the injured worker, these problems seem to be magnified. Early recognition of the extent of injury, the zone of injury, and the need for early soft tissue coverage is essential. With expeditious treatment, wound coverage, treatment of compartment syndromes, and early aggressive rehabilitation, many of the complications of these injuries, including chronic pain syndromes, can be minimized.

Compartment syndrome of the foot in children

Compartment syndrome of the foot following trauma is well known in adults but has not been discussed frequently in texts on pediatric trauma. In the current study, seven children and teenagers were identified as having had compartment syndrome of the foot during a five-year period. The average age at the time of the diagnosis was ten years (range, four to sixteen years). The cause of the compartment syndrome was a crush injury in six patients and a motor-vehicle accident in one. All patients had swelling and pain with passive motion, but none had neurovascular deficits. Only the two oldest children had an osseous injury that necessitated open reduction and internal fixation, but all had elevated compartment pressures ranging from thirty-eight to fifty-five millimeters of mercury (5.07 to 7.33 kilopascals). All seven patients had fasciotomies of the nine compartments of the foot, and the skin was closed primarily within five days after the operation. No patient had complications or needed a skin graft. All patients had a good or excellent result after an average duration of follow-up of forty-one months (range, twenty-three to fifty-three months). Orthopaedists managing children who have a traumatic injury of the foot, especially a crush injury, should have a high index of suspicion for compartment syndrome, even in the absence of severe fracture.

Compartment syndromes of the foot: current concepts

The foot has been mentioned as a site for the development of a compartment syndrome for approximately 9 years. Despite this, very little information exists in the literature containing specifics on the nature of the disorder. Very recent work has shown that crush injuries, forefoot and midfoot fractures and dislocations, and calcaneal fractures are prone to the development of foot compartment syndromes (FCS). The classical clinical signs of pain with passive stretch of the involved muscles, and dysfunction of the nerves that pass through the involved compartments are less helpful in the diagnosis of the syndrome in the foot than elsewhere. Tense swelling of the foot may be of some help in arousing suspicion that a FCS has developed, but the diagnosis is best made by invasive catheterization of the foot compartments. Since recent work has discovered that at least nine foot compartments exist, multi-stick catheterization is recommended. Fasciotomy should be performed when the pressures are significantly elevated, to prevent the development of late contractures. A communication exists between a newly-found compartment of the foot, the calcaneal compartment, and the deep posterior compartment of the leg. A combined pattern of FCS and deep posterior compartment syndromes of the leg exists, and should be remembered by the clinician treating injuries of the foot or leg. Also, a foot injury alone may cause a deep posterior compartment syndrome in the leg. Claw-toe deformity seems to be the primary late sequela of FCS. Local procedures may be of only temporary benefit.