Authors (including presenting author) :
Kwok YK (1), Ng KH(2), Tang YK(2), Ho NT(2)
Affiliation :
(1) Podiatry Department, Queen Mary Hospital, (2)Orthopedics and Traumatology Department, Queen Mary Hospital
Introduction :
Rubber band is an elastic loop of rubber that commonly used for holding multiple objects together. Although there is a warning that rubber band should not be used in the extremity, it is still always being neglected. For neuropathic elderly that with limited self-care ability and social or familial support, the use of rubber band in the lower extremity poses their lower limb in high risk of ischemic change. The presence of loss of protective sensory feedback potentially worsen the condition and may lead to irreversible advance outcome. We would like to present a first reported uncommonly encountered case study for better awareness of this condition and prevention of further cases.
Objectives :
A 75 year-old man with diabetes mellitus, hypertension and hyperlipidemia presented with non-healing left ankle ulcer and left leg cellulitis for two weeks. He was admitted as an in-patient. He and his family member could not recall any trauma before ulceration. X-ray of left ankle and leg showed no underlying osteomyelitis and commented unremarkable. There was persistent discharge over left lower leg wound despite intravenous Tazocin and wound swab revealed heavy Staphylococcus aureus, moderate Diphtheroid bacilli and scanty Pseudomonas aeruginosa. Left leg cellulitis subsequently subsided after antibiotics. However, wound healing progress was poor despite antibiotic cover, good diabetic control and intense wound care for 4 weeks.
Podiatric assessment showed dorsalis pedis and posterior tibialis arteries pulses were not palpable over left leg. Also, there was generalized purplish discoloration (distal to the wound) from toe to mild calf with delayed capillary refill time of left leg. Neurological assessment showed deceased protective sensation of left foot. Wound assessment revealed it was a linear circumferential constriction wound at the left lower leg above the ankle. Medial part of the circumferential wound had already healed with linear scar. There was thick yellowish discharge from the lateral wound, and wound base presented with sloughy yellowish tissue. Owing to the circumferential nature of wound, underlying foreign body constriction was suspected. Sterile equipment was used to probe into the wound. Rubber-band-like material was found in wound bed.
Exploration of the left leg wound was performed in view of the purulent wound discharge and suspected retained rubber band. Intra-operatively, an intact rubber band was found embedded into the subcutaneous layer in the linear circumferential wound which was about 6 cm proximal to ankle level. There was partial scar formation over the rubber band without exposure of underlying muscles or tendons. There was no abscess collection and no neurovascular structures involved with a viable wound edge. The rubber band was cut into two segments and removed easily, followed by thorough debridement and curettage of the wound. Intraoperative imaging confirmed no residual radio-opaque foreign body. The wound was loosely sutured with interrupted stitches to allow for pus drainage. After the foreign body removal and intense wound care, left leg linear circumferential wound healed within 3 weeks. Left leg circulation improved gradually with no more purplish discoloration and capillary refill time within 2 seconds resumed with palpable dorsalis pedis and posterior tibial pulses, comparable to the other side.
Methodology :
Previous literature had described rubber band tied circumferentially in the wrist (Agarwal, 2013; Rasool, 1996), arm (Kumar, 2013) and thigh (Kumar, 1995), while the presence of rubber band causing a non-healing ulcer in neuropathic elderly’s leg had not been described in the current literature. To authors’ knowledge, we are the first to describe rubber band induced ulcer in lower extremity. The patient was an elderly with diabetic neuropathy and poor self-care ability that cannot recall the reason of putting rubber band around the leg. It was believed that he may had put it there with the intention to tighten the loosen socks, which is a cultural habit commonly seen in Hong Kong. He did not receive any podiatry care before this incident and have no insight on the effect of rubber band being tighten around the lower extremity. The presence of rubber band in leg eventually cut into the tissues. As the depth produced by the pressure necrosis by rubber band was only a few millimeters, the wound might be partially healed after passing through stages of infection, granulation, fibrosis, wound contraction, and skin epithelialization over the band, leaving a circumferential scar mark on the surface (Kumar, 1995). The undiagnosed rubber band would pose high risk of irreversible gangrenous change of the foot and ankle region, which was distal to the constriction.
With the aging population, together with the cultural habit of using rubber band to tighten the loosen socks, inadequate foot care education, poor elderly self-care ability and limited podiatric elderly service, it is not surprised to have cases like this reported in the future in the presence of the above risk factors, especially in patients with loss of protective sensation like diabetic patients. This emphasized the role of podiatrist in neuropathic elderly care. Podiatrist is a healthcare professional that specializing in diagnosing and treating abnormal foot and lower limb pathologies. The comprehensive knowledge on lower limb anatomy, pathology, physiology, musculoskeletal and biomechanics equip podiatrists in the best position to deal with abnormal lower limb conditions including wound care. The presence of ischemic sign in this case quickly alarm the alertness of possible foreign body constriction in wound from podiatric aspect that lead to discovery of the rubber band and subsequently avoided the future possible irreversible avascular changes of distal extremity.
Result & Outcome :
We reported a patient with rubber band induced persistent circumferential ulcer in the lower leg, in order to increase the recognition of this uncommon but potentially devastating condition. The recognition of symptoms by healthcare professionals would facilitate the mobilization of patients and patients’ family into better foot care education. In a persistent non-healing ulcer, underlying foreign body should be actively looked for, a holistic assessment and management of the ulcer should be used. This included a multi-disciplinary approach, searching for underlying foreign body and advanced wound management including referral to podiatrist. Reversible risk factors should be corrected, including optimization of diabetic control, achievement of better social support and screening for peripheral neuropathy and vascular insufficiency in order to make an earlier diagnosis. Last but not least, proper education of patients and their carer should be reinforced. Avoid putting constriction band such as rubber band around limbs would be the most important potentially modifiable risk factor to this condition.
