CASE REPORT: RECONSTRUCTION OF A BURNED HEEL WITH A PEDICLE FLAP

Annals of Burns and Fire Disasters - vol. XVII - n. 3 - September 2004

CASE REPORT: RECONSTRUCTION OF A BURNED HEEL WITH A PEDICLE FLAP

Steþpniewski J., Sobczy´nski S., Steþpniewski S.

Department of Paediatric Surgery, Krysiewicz Children’s Hospital, Pozna´n, Poland

SUMMARY. This case report describes the reconstruction of a burned heel using the pedicle flap. The surgical procedure is described, and references are made to the relevant literature.

Introduction

The heel of the foot carries the main weight stress of the body on its surface during both standing and walking (Figs. 1,2).



Fig. 1Weight- and nonweight-bearing areas.

Fig. 1 - Weight- and nonweight-bearing areas.





Fig. 2Vertical foot-floor reaction vector of a normal subject walking at free walking speed. From Simon D.T.: Foot-floor calculated reaction vector. Bull. Prosthet. Res., 18: 309, 1981.

Fig. 2 - Vertical foot-floor reaction vector of a normal subject walking at free walking speed. From Simon D.T.: Foot-floor calculated reaction vector. Bull. Prosthet. Res., 18: 309, 1981.



In common experience, in the heel area, split-thickness and full-thickness grafts can be used only to cover shallow wounds, without bone or tendon exposure, immediately after the injury. These types of grafts are also suitable for provisional covering of granulation tissue.

This covering has a tendency to ulcerate, requiring further skin restoration with a pedicle flap or a free flap with sufficient vessel and nerve supply (Fig. 3).



Fig. 3Secondary heel ulceration in the split-thickness skin graft.

Fig. 3 - Secondary heel ulceration in the split-thickness skin graft.



Parts of the foot that are not subject to weight stress can ultimately be treated with full-thickness grafts without any limitations or restrictions.

For reconstruction of the surface of the heel, we have to use tissue that is similar in its structure and properties, preferably skin originating from an adjacent area.

For the creation of the posterior heel surface and Achilles tendon insertions, Grabb and Argenta’s lateral heel flaps are the best (Fig. 4).



Fig. 4Lateral island heel flap by Grabb and Argenta.

Fig. 4 - Lateral island heel flap by Grabb and Argenta.



These inserts are incised on the dorsolateral heel surface, just below the ankle, as pedicle grafts or free flaps. They usually demonstrate a good blood supply and are innervated by peripheral branches of the sural nerve (distance of stimuli discrimination, about 20 mm).

However, the almost ideal material for reconstructing the heel surface is the fornix of the foot.

Short flexor muscles, along with overlying skin, can be transferred to the calcaneus. Rotation flaps or free flaps with preserved vessels and innervation coming from the medial plantar nerve are used (Fig. 5).



Fig. 5Scheme of vessel anatomy of the foot.

Fig. 5 - Scheme of vessel anatomy of the foot.



Case report

We consider the foot of a 17-yr-old girl with deep heel ulceration after a hot water burn (she immersed her feet in a hot tub) (Fig. 6).



Fig. 6Heel ulceration.

Fig. 6 - Heel ulceration.



The girl had previously sustained a spinal injury with partial medullar damage, which largely contributed to the extent of the burn.

The ulcerations were excised under local anaesthesia.

A 6x7 cm flap consisting of skin and underlying tissue was harvested from the fornix of the foot. Medial plantar vessels and cutaneous peripheral branches of the plantar nerve were included in the flap pedicle, but not short flexor muscles (Fig. 7).



Fig. 7Reconstruction of the heel.

Fig. 7 - Reconstruction of the heel.



The graft was translocated freely to the heel and sutured in, without any tension. There was no need to chisel the calcaneus. Secondary skin deficit on the dorsum of the foot was covered with an intermediate full-thickness graft (Fig. 8).



Fig. 8Fenestration in the dressing on the heel to control flap perfusion.

Fig. 8 - Fenestration in the dressing on the heel to control flap perfusion.



Healing of the wound proceeded normally, and the entire graft survived (Fig. 9).



Fig. 9Good result after 10 months.

Fig. 9 - Good result after 10 months.



Conclusion

Pedicle flaps harvested from the fornix of the foot make a good material for heel surface reconstruction, owing to the similar anatomy, good innervation, and sufficient blood supply.


RESUME. Les Auteurs présentent un cas de la reconstruction d’un talon brûlé avec l’emploi du lambeau pédiculé. Ils décrivent la procédure chirurgicale et font des références à la littérature relative.


Bibliography

  1. May J.W., Halls M.J., Simon S.R.: Free microvascular muscle flaps with skin graft reconstruction of extensive defects of the foot: A clinical and gait analysis study. Plast. Reconstr. Surg., 75: 627, 1985.
  2. Simon S.: Foot-floor calculated reaction vector. Bull. Prosthet. Res., 18: 309, 1981.
  3. Bostwick J.: Reconstruction of the heel pad by muscle transposition and split-skin graft. Surg. Gynecol. Obstet., 143: 973, 1976.
  4. Baker G.L., Newton E.D., Franklin J.D.: Fasciocutaneous island flap based on the medial plantar artery: Clinical applications for leg, ankle, and forefoot. Plast. Reconstr. Surg., 85: 47, 1990.
  5. Daniel R.K., Taylor G.I.: Distant transfer of an island flap by microvascular anastomosis. Plast. Reconstr. Surg., 52: 111, 1973.
  6. O’Brien B.M., Macleod A.M., Hayhurst J.W.S., Morrison W.A.: Successful transfer of large island flap from the groin to the foot by microvascular anastomosis. Plast. Reconstr. Surg., 52: 271, 1973.
  7. Serafin D., Georgiade N.G., Smith D.H.: Comparison of free flaps with pedicled flaps for coverage of defects of the leg or foot. Plast. Reconstr. Surg., 59: 492, 1977.
  8. Grabb W.C., Argenta L.C.: The lateral calcaneal artery skin flap, the lateral calcaneal artery, the lesser saphenous vein, and the sural nerve skin flap. Plast. Reconstr. Surg., 68: 723, 1981.
  9. Hartrampf C.R., jr, Scheflan M., Bostwick J.: The flexor digitorum brevis muscle island pedicle flap: A new dimension in heel reconstruction. Plast. Reconstr. Surg.., 66: 264, 1980.
  10. Skef Z., Ecker H.A., Graham W.P.: Heel coverage by a plantar myocutaneous island pedicle flap. J. Trauma, 23: 466, 1983.

This paper was received on 23 March 2004.
Address correspondence to: Dr Jan Steþpniewski, Department of Paediatric Surgery, Krysiewicz Children’s Hospital, Pozna´n, Poland.