Empty toe phenomenon

A 38-year-old man presented to the ER after a high-impact road traffic accident. The patient had swelling and discolouration of the left third, fourth and fifth digits and dorsum of foot with loss of the touch and pain sensations in lateral left foot and feeble dorsalis pedis pulse.

Plain radiograph of the revealed fractures of the distal phalanges of left fourth and fifth toes with subluxation at the distal interphalangeal joint of the left fourth digit. There was dislocation of proximal, middle and distal phalanges of 5th digit into the 4th web space however the soft tissue sleeve of the 5th toe appeared intact (Figure 1).

Closed degloving injuries result from shearing forces that cause soft tissue separation from deeper fascial planes without disruption of the overlying skin. As the contour of the outer skin is preserved, the severity of underlying injury may be easily overlooked. There may be associated transection of perforating vessels which may cause development of rapid gangrenous necrosis of the superficial soft tissues [1,2]. “Empty toe” is a unique type of closed degloving injury occurring in conjunction with bone displacement. Only 9 cases of such injury have been previously reported [Table 1].

Complications of such injuries include tissue necrosis, infection, hematoma formation, contractures, and neuritis. A potential complication that can occur after severe crush injuries is undiagnosed compartment syndrome [10]. Hudson et al. discovered that closed degloving injuries may be missed in one-third of patients at initial assessment [11]. Closed degloving injuries that go unnoticed can result in contour deformity many months later, necessitating corrective cosmetic surgery [12]. Failure of phalangeal salvage may be due to crushing, severe neurovascular bundle damage, or impaired perfusion of injury sites.

In our case, the patient underwent initial immediate wound debridement and closed reduction. Patient developed necrosis of the skin across the entire length of the lateral aspect of the left foot on day 3, for which repeat debridement was performed.

4 weeks later, the patient had developed necrosis of the fifth digit and underwent a free flap procedure. Intraoperatively, extensive granulation tissue was seen with sparing of the digits. On relook of the free flap one day later, venous congestion was noted in the flap with venous thrombosis and a small perianastomotic hematoma. This was managed with hematoma evacuation and oral anticoagulants.

On the follow-up visit at 08 months, the patient had developed flexion contracture of the left first toe and decreased range of movements in left foot. This was managed with release of tight Achilles tendon, release of contracture and thinning of the flap. Further clinical information is not available as the patient did not follow up for further visits.

Teaching Points:

1. Closed degloving injuries are uncommon and can easily be overlooked.
2. Empty toe phenomenon implies severe injury to the phalanx with potential neurovascular damage.
3. Prompt recognition and management aimed at circulatory restoration is key to satisfactory functional outcome

Written informed patient consent for publication has been obtained.