Puncture wound with delay in presentation of wet necrotic foot

A 38-year-old male Afro-Caribbean patient with type 2 diabetes mellitus of 2 years' known duration, and a body mass index of 31, who had been lost to follow-up after his initial diagnosis, trod on a tin tack. This penetrated the sole of his shoe during his work as a school caretaker. He visited his general practitioner who prescribed a 5-day course of 250 mg amoxicillin tds. After 5 days the patient thought the foot had healed.

Two weeks later, the patient's girlfriend noted greenish discolouration of the sole of his foot and insisted that he attend the hospital casualty department. The plantar surface of the forefoot was bulging, there was deep infection involving the 3rd, 4th and 5th webspaces and the 2nd,

3rd, 4th and 5th toes were necrotic, although this was not immediately apparent because the dorsum of the foot was heavily pigmented (Fig. 6.2a). He was admitted to hospital for intravenous antibiotics and surgical debridement, and four toes and their adjoining metatarsal heads were removed. Once the infection was controlled he insisted on returning to work. He was treated in a total-contact cast, and healed in 6 months (Fig. 6.2b). He was physically very active and his casts needed additional strengthening and very frequent replacement. On one occasion, the day after his cast had been applied, he went for a very muddy walk on Dartmoor, a national park renowned for its bogs and rocks, in his cast and returned to the clinic with the cast in tatters. He developed end-stage renal failure but continued to work and to lead an active life and while on holiday in Spain dialysed in the local restaurant by hanging his CAPD bag from a hat stand. Two years after his admission for the foot problem he was found dead in bed from a myocardial infarction.

Key points

• Untreated infection can rapidly lead to necrosis

• Puncture wounds should be followed up very carefully as signs of infection will only become apparent when they have spread from the deep tissues to the superficial structures

• Bulging of the plantar surface indicates deep infection with collection of pus which needs drainage

• In the neuropathic foot, extensive necrosis can be

Fig. 6.2 (a) Plantar view of infection following a puncture wound which has led to wet necrosis of the forefoot requiring amputation of four toes and their adjoining metatarsal heads, (b) Full healing of the very large postsurgical tissue defect took 6 months. He wore a total-contact cast

Metatarsal Extra Toes

to off-load the wound.

successfully treated by surgical debridement with eventual complete healing

• Physically active and heavy patients need extra-strong casts.

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