A rare case of closed degloving injury of the fifth toe
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A 22 year old male motorbike driver presented in the emergency department (ED) because his right foot was crushed by a trolley bus, with no other injuries. His foot had significant edema, with a deformity of the fifth metatarsal and of the fifth toe but the skin was intact. The fifth toe was extremely flexible, insensate, and with no capillary refill. The dorsalis pedis artery was palpable, but the digital arteries of the fifth toe could not be found on Doppler ultrasonography. The patient presented to the ED approximately 2 h after his injury.

Plain imaging identified a dislocation of the fifth toe with only the distal phalanx being contained under the skin. There was also a nondisplaced fracture of the fourth metatarsal. Time from patient arrival in the ED till the completion of diagnostic test (clinical examination, radiographs, Doppler ultrasonography) was approximately 20 min. However, 48 h after the operation the distal phalanx of the fifth toe displayed signs of inadequate perfusion and necrosis as there was no capillary refill and no sensation of the plantar area of the distal phalanx, while the rest of the toe seemed normal. Doctors decided to wait and observe the progress of the necrosis. Five days postoperatively the patient was discharged and he was followed up as an outpatient every three days. He was non-weight-bearing for the first two weeks postoperatively and was under enoxaparin 4000 IU and acetylsalicylic acid 100 mg once per day.

He started hyperbaric oxygen therapy ten days after the fasciotomies. He completed three sessions within twelve days. The toe was checked for edema, sensation, and temperature in the follow up visits. One month after injury the necrotic area of the middle and distal phalanx which included the nail-bed was amputated. The patient had uneventful wound healing and has had painless ambulation on the affected limb at the six month postoperative visit. In conclusion, prompt recognition and treatment (prompt restoration of circulation and avoidance of compartment syndrome) can affect both viability and clinical outcomes in a number of cases, as well as the eventual need for amputation and the amount of tissue removed.

Source: https://www.sciencedirect.com/science/article/pii/S2352644020300820?dgcid=rss_sd_all
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