Reconstruction of Severe Foot Injury

Patient Review

Patient’s Age: 40 years old
Patient’s Gender: Male

Symptoms

The left foot split horizontally into two parts, with all toes except the little toe amputated
Fracture in right thigh bone
Left foot displayed significant swelling, open wounds with exposed and broken bones, and necrotic tissue and contamination
Intense pain and numbness in the injured areas

Case Presentation

The patient, a railway employee, presented with a high grade injury to his lower limbs, resulting from a railway accident. He suffered from a fracture in his right thigh and a crush injury to his left foot, resulting in a partial amputation where all but the little toe were lost. The left foot was extensively damaged with contamination, dead skin, and multiple fractures.
Upon arriving at the emergency department, Dr. Leena Jain was consulted for her expertise in managing complex wounds. Due to the severity of his injuries, the patient had been on a ventilator for the first 24 hours. Despite the extensive damage, the remaining part of the left foot, including the 5th toe, showed intact circulation and sensation. A thorough surgical debridement was performed to clean the wound of all contaminants and necrotic tissue.

Physical Examination & Tests

Physical examination showed extensive soft tissue damage, contamination, and necrosis in the left foot. Circulation and sensation in the remaining part of the foot, including the fifth toe, were intact. The right thigh presented with a closed fracture.
Initial tests included:

X-rays of the left leg with foot and right thigh to assess the extent of bone fractures and joint involvement
All other pre-operative investigations

Treatment

The initial surgery involved debriding the wound to remove all necrotic and contaminated tissue and stabilise the skeletal structure of the crushed foot. After 48 hours, a relook debridement was planned. He was then planned for a flap cover to resurface all the wounds. Dr. Jain took a flap from the right side of the patient’s back, including a skin paddle. This is called the latissimus dorsi flap. Muscle with skin graft was used to cover most of the defect on front of the foot while the skin paddle was used to cover the distal part of the foot giving it a stable and robust cover, wherein later prosthetic toes can be placed, The flap and graft integration was successful, with the back scar healing within 10 days and the reconstructed foot showing a significant improvement over a month. After two months, all wires were removed and patient was allowed to bear partial weight on his foot and start walking.

Prognosis

The patient’s prognosis was favorable with the successful integration of the flap and graft. After a period of healing, which included the removal of internal fixation devices used for fracture treatment, the patient could bear weight on both feet. He began walking with customized modified shoes after 8-10 weeks, and a silicon prosthesis is planned to replace the lost toes for aesthetic and functional purposes.

Patient Feedback

The patient expressed significant satisfaction with the outcome of the reconstructive surgeries. The successful restoration of foot function and appearance has greatly improved his quality of life. He appreciated the careful planning and execution of the treatment plan, as they allowed him to return to normal activities and work life.

Conclusion

This case highlights the challenges and successes in managing severe crush injuries and amputations, to salvage and prevent further shortening of limbs; thereby aiding in ambulation. It demonstrates the importance of intact skin and soft tissue and sensation in reconstructive outcomes, and the patient’s positive feedback underscores the effectiveness of well-planned reconstructive surgery in restoring function and appearance.