The Twig-Brook Lesion In Barefoot Waders; A Common But Neglected Injury In The Foot

摘要

Penetrating injuries of the foot are very common. Although apparently straightforward, delayed diagnosis, inappropriate approach and treatment can lead to complications and unsatisfactory results. We present our diagnostic and therapeutic approach using an outcomes approach and clinical results in a commonly seen lesion in our state which occurs due to the penetration of wooden twigs or splinters while wading barefoot through small streams or brooks which we have named the twig-brook lesion. Introduction Penetrating foot injuries of all types are very common. There are some types of such injuries that are typical of a certain region due to certain local factors like barefoot walking, farming, presence of certain animals or parasites and hygiene etc. A classical penetrating injury seen in this part of Southeast Asia occurs when people wade barefoot through shallow streams or brooks and cannot discern if any sharp objecct is present beneath their feet till they feel a twinge of pain. Usually, the person comes out of the water and examines the foot to find a small wound on the plantar aspect of the foot with some blood oozing out of it. The woung is generally dismissed as minor and ascribed to some sharp stone present in the stream and not attended to. However, the wound is persistent and does not heal even after the patient seeks medical attention, usually from the local medical shop. The patient usually seeks specialised attention only after 2-3 months have passed and there is a sinus formation with occasional pus discharge. Radiography is unhelpful and exploration of the wound done under torniquet control invariably reveals a wooden twig or splinter which is surrounded by necrotic tissue and pus which forms a pathway till the sinus opening. Removal of the foreign body with meticulous debridement and healing of the wound by secondary intention resolves the lesion. Materials and Methods Between 2005 and 2009, 67 patients (47 M and 20 F; mean age- 28, range 8 to 53; follow-up: mean 2.5Y range of follow-up 2–4 years) were treated for neglected penetrating foot injury following barefoot wading in shallow brooks. The patients presented with plantar wounds which were not healing and sinus formation with intermittent pus discharge. The duration of injury ranged from 3 weeks to 15 weeks with an average of 7 weeks. Each patient had a routine x-ray of the foot but sonography was not done as it was not available in our setup. The patients were operated under regional or general anesthesia and torniquet control. Postopertively, the patients were kept on systemic antibiotics for 5 days. Results The presence of a foreign body inside the foot tissues was detected in 63/67 patients (94%) and they were operated upon by meticulous debridement and removal of foreign body(FB). In the remaining 4 patients we could not trace any sizable FB but we could remove organic debris and traces of bark. Complete healing was observed in 64/67 (95%) of patients, although 6 /67 (9%) underwent secondary debridement. There were no bony pathologies and the infective pathology was confined to the soft tissues only.