[SavageGlow]

As above, so below

[kellyhound]

Achilles snake

A 60-year-old male was presented to our level 1, major trauma centre, with an open injury to the posterior aspect of the left heel. following an accidental fall on a tugboat.

He reported descending a set of stairs backward, when his left foot got caught in between two steps resulting in forced dorsiflexion and fall three metres down the stairs.

This resulted in an open wound to the posterior aspect of the left heel, extending from the medial to lateral malleolus.

Initial primary and secondary surveys were otherwise unremarkable with this being an isolated injury to the left ankle.

His co-morbidities included type 2 diabetes mellitus (managed with oral therapy), hypertension, two previous strokes, hypercholesterolaemia, gout and obesity.

He was previously independent with all activities of daily living, a non-smoker, and independently mobile. Although no fracture was present, the patient's initial treatment was in line with British Orthopaedic Standards for Trauma (BOAST) for Open Lower Limb Fractures and he was given a dose of IV Co-Amoxiclav, and, after being photographed, the wound covered in saline-soaked gauze with an overlying occlusive film.

The patient underwent a joint Orthoplastics procedure in which an attempt was made to primarily re-attach the avulsed tendon to the muscle belly.

This was then covered with a concurrent lateral rotational flap. Ten days later, the distal aspect of the flap was found to be necrotic with eschar. This warranted further washout and debridement of the wound.

The defect was left open and managed with vacuum-assisted closure (VAC) therapy. A provisional plan was made to close the defect with a free flap at a later date.

Six days later, the patient was discussed in the Orthoplastic multidisciplinary team (MDT) meeting, where it was decided to excise the non-viable tendon to allow coverage of the defect with a SSG.

This was closely monitored by the Plastics team. A week later, after further input from the Orthoplastic limb reconstruction MDT team, this gentleman went on to have an anterolateral thigh (ALT) flap.

It was decided that a flexor hallucis longus (FHL) tendon transfer could be considered later if functionally required.

The patient was followed-up in the outpatient Plastics and Orthoplastic outpatient clinic for monitoring of graft. Graft take was over 95%. However, assessment at the Orthopaedic clinic found that his left foot was fixed in 30° dorsiflexion.

Efforts to correct this resulted in involuntary firing of the unopposed tibialis anterior. The patient will therefore require further operative intervention to correct this deformity and permit ambulation.

This is likely to take the form of an arthroscopic ankle fusion rather than an FHL tendon transfer and ALT flap given prior flap failure and successful take of the SSG.

[Mr.NoCredit]

I suffered a ruptured thumb flexor tendon in my right forearm. It broke loose and rolled up in my forearm like a broken rubber band. Passed out on the spot while talking to my ex-girlfriend on the phone one evening. It was gnarly…