LAUSR

A 21-year-old male wearing full protective gear sustained a blunt traumatic injury to his left foot whilst dirt-bike riding, when he struck a concealed log. He presented to the emergency department with mild bruising along the lateral aspect of his foot and a pale, swollen little toe (Fig. 1). Dorsalis pedis and posterior tibialis pulses were intact. Palpation of the digit was suspicious for absence of bony elements. Plain radiographs revealed fractures of the metacarpal neck and proximal phalanx of the little digit. In addition, the toe itself consisted of a soft tissue shadow only, with displacement of the bony elements into the adjacent web space and digit, indicative of an internal degloving injury (Fig. 2). Reduction was performed under sedation, via longitudinal traction and adduction of the soft tissue envelope and gentle manipulation of the bone. Although the toe regained a relatively normal structure, it remained pale, and repeat radiographs demonstrated increased soft tissue shadowing and length of the distal pulp. This likely represented a collection of avulsed soft tissue structures. Magnetic resonance imaging revealed a wide zone of soft tissue injury, and no appreciable intact neurovascular structures. After discussion with the patient, a decision was made to allow the soft tissue injury to settle and demarcate prior to any operative intervention. At the 10-day mark, the fifth digit had developed dry gangrene, with a surrounding zone of non-viable tissue (Fig. 3). The patient was taken to theatre, and a partial ray amputation performed to the level of the mid-metatarsal shaft. A vacuum dressing was applied to allow staged closure a week later, due to the extensive oedema of the surrounding tissues. The wound matured well, and the patient was discharged at 8 weeks post-injury (Fig. 3). He returned to manual labour at 3 months, with no functional limitations. Although open degloving injuries are somewhat common, closed degloving injuries of the foot are extremely rare, and their severity can be underestimated. Only seven prior cases have been reported in the literature. All resulted from blunt shearing trauma. The mechanism of injury is postulated to be a combination of longitudinal and dorsoplantar compression forces applied on the phalanges whilst the soft tissue tip of the toe remains fixed, resulting in disassociation of the bones and the surrounding subcutaneous tissues. This mechanism is similar to that of a ring avulsion, and is associated with high risk of damage to neurovascular