Multidisciplinary Reconstruction of a Severe Foot Degloving Injury Using a Radial Forearm Free Flap: A Case Report
Degloving soft tissue injuries (DSTIs) are severe, limb-threatening traumas caused by high-energy shearing forces, most commonly motor vehicle accidents, that separate the skin and subcutaneous tissues from underlying structures and often compromise neurovascular integrity.1 Although uncommon, with reported incidence as high as 4% among trauma patients at a Level I trauma center, DSTIs disproportionately affect younger males compared with females.1-4 Despite their rarity, these injuries present significant challenges for the surgical team and can lead to devastating lifelong sequelae.
Initial management typically involves incision and debridement of nonviable tissue to determine the true extent of injury, followed by reconstruction tailored to the available soft tissue and the size and location of the resulting defect. DSTIs of the lower extremity are particularly complex due to involvement of joints, flexion points, and weightbearing surfaces. When there is substantial tissue loss present, soft tissue flaps remain a cornerstone of reconstruction.
We present a case of a traumatic foot degloving injury that, following extensive debridement, underwent reconstruction using a free radial forearm flap anastomosed to the anterior tibial vessels, along with split-thickness skin grafting to both the foot and donor site. This case highlights the surgical decision-making, interdisciplinary collaboration between the podiatry and plastic surgery teams, and the technical challenges involved in complex foot reconstruction after severe soft tissue trauma, while further supporting existing literature demonstrating the effectiveness of the free radial forearm flap for lower extremity wound management.
Key Points in the Case Presentation
A 32-year-old female presented by ambulance after sustaining a degloving injury to the right foot in an electric scooter versus vehicle accident. She reported swerving to avoid a car, but was struck, with the vehicle running over her right leg. She denied loss of consciousness, and her Glasgow Coma Scale (GCS) was 15 on EMS arrival. Past medical history included prior opioid use disorder, stable on suboxone.
On exam, the right foot was neurovascularly intact with +2 pitting edema. A complete medial foot degloving was noted from the ankle to the hallux, with osseous exposure consistent with Gustilo Anderson IIIb (Figure 1).5 Plain film X-rays revealed nondisplaced fractures of the first and second metatarsal heads (Figure 2).
The patient underwent emergent irrigation, debridement, and application of a biologic tissue graft derived from the extracellular matrix (ECM) of porcine urinary bladder. Intraoperative findings included periosteal stripping of the first metatarsal and medial cuneiform, nondisplaced fractures of the first and second metatarsal heads, a small medial cuneiform avulsion fracture, rupture of the tibialis anterior tendon, denuded extensor hallucis longus tendon, and complete disruption of the medial dorsal cutaneous nerve (Figure 3). Following debridement, the wound measured 14.5 × 8.0 × 1.0 cm and was covered with powdered and sheet forms of the porcine ECM graft, as this serves as a scaffold to guide the body’s natural tissue regeneration, helping limit scarring and enhance healing.
Two days later, the patient underwent a repeat debridement and washout, followed by negative pressure wound therapy placement. Cultures from the initial surgery showed no growth. One-week post-injury, the plastic surgery team performed excision and debridement, a free radial forearm flap transfer with anastomosis to the anterior tibial artery and vein, and split-thickness skin grafting from the right thigh to both the foot and flap donor site. Postoperative recovery was uncomplicated with non-weight-bearing, use of a posterior splint in dorsiflexion, and regular flap checks. (Figures 4 and 5).
At 6 weeks, the flap was viable and the patient remained non-weight-bearing. By 8 weeks, the graft was well incorporated, and she progressed to weight-bearing in a postoperative shoe (Figure 6). Physical therapy began at 14 weeks. At 20 weeks, the patient reported persistent foot pain and instability, precluding return to her labor-intensive warehouse job. By 28 weeks, she was ambulating in regular shoe gear with a cane. At 2.5 years postop, she continued to ambulate with a cane and reported difficulty with shoe wear due to flap bulk (Figure 7). Flap debulking was considered but not performed, as the patient was lost to follow-up. To date, we do not believe she has returned to her warehouse job.
Discussion and Observations
Degloving soft-tissue injuries (DSTIs) of the foot and ankle are uncommon, and consequently large cohort data remains limited. The largest US-based cohort to date, published by Velazquez and team, reported a 22-year retrospective review of 188 extremity degloving injuries, most of which involved the lower limb.4 In their study, 96% of injuries resulted from motor vehicle collisions or heavy machinery. This is consistent with the mechanism of injury in our patient. The majority of patients (82%) required skin grafting, and approximately 86% received adjunctive negative pressure wound therapy. As expected, deeper injuries involving subcutaneous tissues, fractures, or other critical structures had an association with higher rates of complications and amputation.
Despite our patient sustaining open fractures, they did not experience these adverse outcomes. Interestingly, the review also noted that the presence of medical comorbidities did not influence complication rates, amputation risk, the number of required procedures, or time to healing. This is an unexpected finding that contrasts with typical assumptions in wound healing.
Zhou and team published a retrospective series of 105 patients treated over 12 years.1 Similar to our case, most patients required multiple staged debridements before proceeding with definitive reconstruction. The authors emphasized the importance of an individualized treatment strategy that considers defect size, depth, location, and the patient’s pre-injury activity level to establish realistic expectations regarding recovery and reconstructive options. As expected, patients over age 65 experienced longer healing times and delays in returning to activities of daily living. Although our patient was well below this age group and did not demonstrate delayed wound healing, she ultimately did not return to her pre-injury activity level due to persistent bulkiness of the flap.
When large soft-tissue deficits accompany a degloving injury, achieving durable coverage is critical for maintaining limb function. Exposed tendons, bones, and joints place the patient at high risk for wound chronicity, deformity, and loss of function if not properly reconstructed. The radial forearm fasciocutaneous free flap, first described in the 1970s, remains a reliable option for foot and ankle defects.6,7 Its robust vascular pedicle, dependable innervation, and favorable tissue thickness make it particularly suitable for the mechanical demands of weightbearing surfaces. Musharafieh and colleagues reported a series of 17 patients undergoing radial forearm free-tissue transfer to the foot or ankle, achieving a 100% flap survival rate with a mean follow-up of nearly 4 years.8 Of the 16 patients reconstructed on the plantar surface, 13 returned to normal ambulation; only 3 required shoe modifications, none of whom required debulking. In contrast, our patient experienced persistent graft bulkiness, and debulking has been discussed though not yet pursued.
Alternative reconstructive options also exist. The pedicled lateral supramalleolar flap has demonstrated utility for lateral forefoot defects with exposed bone and tendon. Hassan and team reported a successful outcome using this technique in a patient with a wound pattern similar to the case presented here, underscoring its role as a viable regional flap when free-tissue transfer is not indicated or feasible.9
In Conclusion
Degloving soft-tissue injuries of the foot are highly complex and often involve more extensive damage than initially appreciated on presentation. Early, aggressive irrigation and debridement are essential to fully assess the extent of tissue loss and guide the development of an effective surgical plan. Multiple staged debridements and antibiotic therapy are frequently required, particularly in the setting of vascular compromise or evolving infection. Once the wound environment has stabilized, definitive reconstruction can proceed with the goal of restoring durable coverage and maximizing functional potential.
In this report, we described a patient who sustained a traumatic foot degloving injury and underwent reconstruction with a free radial forearm flap in collaboration with our plastic surgery colleagues. Although the patient continued to experience some limitations in mobility related to the initial trauma, the flap itself has remained stable without wound complications, underscoring the reliability of the radial forearm flap as a reconstructive option for complex foot degloving injuries.
Dr. Frey is a resident at Denver Health and Hospital Authority in Denver, CO.
Dr. Gorski is an attending podiatrist at Denver Health and Hospital Authority in Denver, CO.
References
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