Treatment options for soft tissue defects in severe foot trauma in children

Objective: Severe foot trauma in children is a therapeutic challenge, with presence of devitalised and soiled distal tissues. Several reconstruction and covering procedures can be applied, including artificial dermis (AD), negative pressure wound therapy (NPWT), fasciocutaneous flaps and free flaps. Here, we have developed and evaluated an algorithm for treating severe foot injuries with skin defects in children Method: Paediatric cases of severe foot injury treated over a 16-year period were retrospectively reviewed. Characteristics of the injuries, surgical procedures, complications and the modified Kitaoka score (clinical and functional rating score of the ankle and foot) were recorded. Results: A total of 18 children were included. The mean age at the time of injury was four years and 10 months (range: 1–11 years). The mean follow-up period was 6.2 years. Of the children, 13 presented with an amputation (12 partial foot amputations and one whole ankle and foot). The skin defect was combined with tendon exposure in nine cases, and/or bone and cartilage in seven cases, and heel damage in two cases. A flap was implemented in eight cases, of which one failed. NPWT was used in 13 patients (for an average of 21 days) and was combined with AD in six patients. The mean modified Kitaoka score was 68 (range: 55–80). Additional surgery during the follow-up period was required in seven patients (dorsal skin retraction, a thick flap, osteoma, trophic ulcer or ankle deviation). Conclusion: Our algorithm suggests different therapeutic strategies for skin coverage and healing, depending on the size of the lesion and the exposed structures, and seems to offer good results. These procedures should be combined with NPWT to optimise these results (improved healing, reduced infections, decreased skin defects and enhanced granulation tissue) and so should be used more frequently.

Diagnosis and Treatment of Peritalar Injuries in the Acute Trauma Setting: A Review of the Literature

The bony and ligamentous structure of the foot is a complex kinematic interaction, designed to transmit force and motion in an energy-efficient and stable manner. Visible deformity of the foot or atypical patterns of swelling should raise significant concern for foot trauma. In some instances, disruption of either bony structure or supporting ligaments is identified years after injury due to chronic pain in the hindfoot or midfoot. This article will focus on injuries relating to the peritalar complex, the bony articulation between the tibia, talus, calcaneus, and navicular bones, supplemented with multiple ligamentous structures. Attention will be given to the five most common peritalar injuries to illustrate the nature of each and briefly describe methods for achieving the correct diagnosis in the context of acute trauma. This includes subtalar dislocations, chopart joint injuries, talar fractures, navicular fractures, and occult calcaneal fractures.

Foot Trauma

Chapter 24 reviews the mechanism of injury, imaging strategy, imaging characteristics, and treatment of foot trauma including the calcaneus, talus, navicular, Lisfranc joint, metatarsals, and phalanges. Classification of fractures and associated injuries are also discussed. Radiographs should be performed first in the evaluation of foot trauma. Standard views of the foot are anterior-posterior (AP), lateral and oblique. CT with multiplanar reformats is commonly used for preoperative assessment of calcaneal fractures and can show tendon entrapment. CT examination is also frequently performed for talar head, neck and body fractures for presurgical planning to assess the degree of displacement, joint reduction, comminution and intraarticular involvement.