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Trench foot following a collapse: assessment of the feet is essential in the elderly
Gethin L. Williams, Anthony E. Morgan and John S. Harvey
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). 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.
The approaching 90-year anniversary of United States entry into the Great War is an apt time to examine the response to trench foot (now called nonfreezing cold injury [NFCI]) in this conflict. Trench foot appeared in the winter of 1914, characterized by pedal swelling, numbness, and pain. It was quickly recognized by military-medical authorities. There was little debate over whether it was frostbite or new condition, and it was quickly accepted as a specific disease. The major etiologies proposed were exposure, diet, and infection. The opinion emerged that it was caused by circulatory changes in the foot caused by cold, wet, and pressure. Predisposing factors included dietary inadequacy and fatigue. A number of labels were first given to the disease. However, the name "trench foot" was eventually officially sanctioned. Trench foot became a serious problem for the Allies, leading to 75 000 casualties in the British and 2000 in the American forces. Therapy for trench foot involved a number of conventional, tried-and-tested, and conservative methods. Some more innovative techniques were used. Amputation was only used as a last resort. Prevention involved general measures to improve the trench environment; modification of the footwear worn by the men; and the provision of greases to protect them from moisture. The medical reaction to this condition seems to have been relatively effective. The causation was identified, and prophylactic measures were introduced to fit this model; these seem to have been successful in reducing the prevalence of the condition by 1917-18.
Re: Trench foot in an older person following a fall
The BBC are reporting: I got trench foot at Glastonbury
Every year I can, I go to the Glastonbury Festival and pick up a T-shirt or two as a memento. But last year's souvenir was unexpected and certainly unwelcome. I came home with trench foot.
Podiatrist Amber Kibby is a trustee director of Festival Medical Services, a charity which provides medical services at Glastonbury. Its 13 festival podiatrists are familiar with the symptoms of trench foot.
"The team started its work in 1998, which was the worst year for trench foot. We were seeing approximately 90 cases a day. Over the years, we have seen less and less of the condition. On the whole people are better prepared and they bring socks and wellies, they understand that there will most likely be mud."
Re: Trench foot in an older person following a fall
Trench foot was first described in the Great War and was attributed to the feet being immersed in very cold mud for long periods of time. It was also known but not described as a condition during the Napoleonic Wars when the French troops were deployed to Russia with inferior footwear. A long tradition with Russian servicemen was to wear Ugg boots (called valenki) to prevent frostbite and Trench Foot. In the Great War the forces footwear was no match for the atrocious conditions of the water filled trenches. When soldier’s legs and feet were immersed in cold muddy waters for weeks on end their ligaments gave way and their feet collapsed. This left the combatant unable to move. More and more complained of symptoms ranging from cold feet, pins and needles (paraesthesia) to no feeling whatsoever. Walking in severe cases was impossible and when the casualties mounted this created a major problem which was met with greater attention to foot hygiene. This event most certainly had an effect upon the general importance given to chiropody after the Great War. During the Second World War footwear supplies to the front were fatally delayed because vital supplies were misappropriated by Black Marketeers. It was quite common to find non-combat units wearing superior footwear intended for their colleagues at the front. In the Second World War, trench foot was responsible for putting more Allied Forces out of action than the German 88 (artillery). In December 1944, Northern Europe's witnessed it's coldest winter during which 45,000 men - the equivalent of three full infantry divisions, were pulled out of the front line because of trench foot. Three days before the Battle of the Bulge began so great were the casualties to trench foot, men unable to walk were carried from sheltered pillbox positions at night to firing positions in the day time. Behind the US Lines it was decreed any soldier suffering trench foot would be tried for court martial. Senior officers were suspicious some soldiers were hoping to avoid combat by actively encouraging symptoms of trench foot. One reason why trench foot was so common was soldiers slept with their boots on. During engagement they were recommended to dry and warm their feet as best they could, and sleep with their boots off. This was often impractical and most ignored the directive. Conditions in the Falklands War were extreme. The British soldiers were severely challenged by their inferior boots. The direct moulded sole failed to keep their feet dry and water poured through the lace holes. The impermeable sole provided a perfect reservoir and feet was immersed in cold water for long periods. Trench foot was commonplace and a major concern to the assault forces. The Argentine boot was superior in every way and provided ideal protection to the elements; hence it became a valued prize of war. A morbid and sordid fact of war was the boots of the dead were removed in order to continue combat. In the Falklands War there was a reoccurrence of Trench Foot because the boots of the British Forces' were unsuitable for the weather conditions. Some military experts have postulated had the Argentineans been prepared to prolong hostilities they would have won because of the British casualties to Trench Foot.
Loss, hunger and mass displacement are just some of the problems of a natural disaster. With tens of thousands of Katrina hurricane survivors crowded into shelters around the New Orleans and others refusing or were unable to leave spots contaminated by floodwaters, disease plays a major problem. Trench Foot was identified and did not discriminate between survivor and rescuer. The present floods in the US and natural disaster in China are likely to see similar incidences. Trench Foot is now sadly commonly reported in homeless people living rough ion the streets of towns and cities.
A similar condition to Trench Foot is Immersion Foot and is associated with prolonged exposure to warm and wet conditions. This was common in Second World War and Vietnam, where fighting in the jungle swamps necessitated combatants remained in warm moist conditions for long periods of time. Immersion Foot was seen more recently in the 2004 Asian Tsunami.
The misfortunes of a US boot making companies were transformed with the wars in Afghanistan and Iraq. Although 90% of US shoes are manufactured overseas there is a US federal law which states all military footwear should be made from cow hides of American cattle. War meant a new lease of life for ailing traditional industries. At first the mountainous terrain of Afghanistan was a major challenge to the boot designers. During the winter in the mountains the snows can be anything from waist height to over the head and since much of the campaign covert tell tale boot prints gave away the presence of strangers. Landmines were a major problem and despite the sophistication of design and material, no army boot has yet been able to prevent injury. Official US Government research indicates the spectrum of lower leg injuries is the same whether wearing sandals or standard army boots. At best the purpose of the army boot is to prevent below knee amputation for small charges and above the knee for large charges. Combat troops keen to avoid detection wore sandals made from old tyre treads.