Age and Ageing 2005 34(6):651-652; doi:10.1093/ageing/afi191
© The Author 2005. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org
Trench foot following a collapse: assessment of the feet is essential in the elderly
Gethin L. Williams,
Anthony E. Morgan and
John S. Harvey
Department of General Surgery, Llandough Hospital, Penarth, Cardiff CF64 2XX, UK
Address correspondence to: G. L. Williams. Fax: (+44) 29 20715416. E-mail: geth_williams{at}yahoo.co.uk.
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Abstract
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Elderly patients commonly present to hospital following a collapse
and period of distressing immobilisation on the floor. We present
a case of bilateral trench foot in such a patient with no prior
peripheral vascular disease. Examination of the feet is mandatory
for early detection of this rare condition in the collapsed
elderly patient.
Keywords: trench foot, elderly, collapse
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Introduction
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The condition known as trench foot or immersion foot is usually
associated with damp and cold settings such as warfare. It accounted
for many casualties in both World Wars and also more recent
conflicts such as the Korean, Vietnam and Falkland wars [
1].
It has also been recognised as an increasing problem in the
homeless and vagrant populations [
2]. Here we report how a combination
of old age and collapse led to bilateral trench foot. This case
illustrates the vigilance and the holistic approach needed when
managing the elderly patient presenting to hospital following
an immobilising fall.
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Case report
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A frail 79-year-old man who lived alone was admitted to hospital
after being discovered by neighbours on his kitchen floor in
the month of February. The temperature at the time of his admission
was relatively mild; although cold, the ambient temperature
was above freezing. He remembered losing his balance and falling
to the floor, but being unable to get back to his feet. He sustained
no head injury or bony fractures, but was on the tiled floor
of his kitchen for 48 hours. He was known to have carcinoma
of his prostate gland; the attending paramedics noted that his
trousers and the slippers he wore on his feet were soaked in
a pool of urine.
On admission he was hypothermic (34°C) and profoundly dehydrated. There was no evidence of myocardial infarction or any thromboembolic event. The following day it was noted for the first time that his feet were markedly discoloured. Examination revealed that both feet were swollen and cold with signs of ischaemia of all ten toes; there was no surrounding erythema, no pressure sores and all pedal pulses were manually palpable bilaterally. Arterial duplex of his lower limbs showed no major arterial disease of his vessels down to his posterior tibial and dorsalis pedis arteries and no evidence of emboli. A diagnosis of bilateral trench foot was made. He was initially treated conservatively with bed rest, intravenous antibiotics, elevation and correction of his dehydration.
Over the following fortnight dry gangrene developed in both feet along with an obvious line of demarcation (Figure 1). Since his improvement following his admission it was decided at 4 weeks to electively amputate the gangrenous toes of his left foot and his affected right forefoot. His stumps healed well but he succumbed to bronchopneumonia 17 days postoperatively.
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Discussion
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Trench foot is a clinical syndrome caused by prolonged exposure
of a healthy foot to a non-freezing, moist, occlusive environment.
In most circumstances recovery is complete, however, severe
complications such as gangrene, nerve and muscle injury may
be seen.
This elderly man’s trench foot seems to have been caused by several coexisting factors. The cold temperature of his kitchen floor, muscular inactivity, damp tight footwear, dehydration and his malignancy—all had a role to play in the development of his gangrenous toes. The first description of this painful and debilitating condition appeared in the Napoleonic Wars, but it was commonly seen as a curse of the soldiers of World War 1 who stood for days in tight boots in soaking trenches. It is far from common outside wartime but an upsurge of trench foot in homeless people has been described by some authors [3].
This case serves as a reminder to all health care professionals dealing with elderly patients. Those who are admitted to hospital following an unexplained fall and having suffered a long period of immobility on a cold floor are at high risk of developing trench foot. Cold injury of the foot does not require sub-zero temperatures but is caused by prolonged exposure of feet to cold, damp conditions associated with immobility and constrictive clothing. Awareness of the condition, prompt recognition and aggressive symptomatic support and resuscitation should be the best course of action. However, in those elderly patients with severe trench foot on admission, early amputation would decrease the high morbidity and mortality associated with this condition [4].
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Key points
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- Trench foot may occur despite our comparatively mild climate.
- Elderly patients admitted following a collapse and immobilisation should be assessed for the possibility of trench foot especially when soaking of the feet has occurred.
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Conflicts of interest
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None.
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Funding
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None.
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References
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- Ungley CC, Channel GD, Richards RJ. The immersion foot syndrome. Br J Surg 1946; 33: 17–31.
- Parsons SL, Leach IH, Charnley RM. A case of bilateral trench foot. Injury 1993; 24: 680–81.[Medline]
- Wrenn K. Immersion foot: a problem of the homeless in the 1990’s. Arch Intern Med 1991; 151: 785–88.[Abstract/Free Full Text]
- Ramstead KD, Hughes RG, Webb AJ. Recent cases of trench foot. Post Med J 1980; 56: 879–83.
Received June 4, 2005; accepted in revised form August 17, 2005.
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Abstract
Introduction