Traumatic Heel Pad Avulsion in a Pediatric Patient

Abstract

Introduction: Heel pad injuries can have devastating and debilitating consequences. All efforts to primarily reapproximate the heel pad should be undertaken. Reconstruction of the heel pad can often require multiple complex surgeries including microvascular flaps and tissue transfers. There is a paucity of successful techniques for primary repair in the literature. Case Presentation: In this case report, we describe the successful use of polydioxanone suture with sterile buttons for the repair of the heel pad in a pediatric patient. An 8-year-old male was struck by a vehicle, sustaining a full-thickness heel pad avulsion injury measuring approximately 16-cm in length. The soft tissue was sharply debrided and repaired primarily to the calcaneal periosteum using #1 polydioxanone suture with external suture buttons, and an incisional wound VAC was applied. He was placed into a long-leg bent knee cast and kept non-weight bearing for a total of 6 weeks, at which time the suture and buttons were removed and he was progressed to weight bearing as tolerated in a walking boot. At the 6-month follow-up examination, the heel pad was viable and well-fixed; the patient reported no pain and was not limited in any chosen activities. Conclusion: This construct was shown to provide effective fixation while mitigating reported concerns of tissue necrosis caused by suture repair. At 1 year from injury, the patient’s mother noted a slight limp with running but not with walking. He reported no pain at any time, and his Oxford Ankle-Foot Questionnaire for Children score was 58, indicating excellent patient-reported outcome following his procedures.

Adult Traumatic Heel Pad Avulsion Repair with Polydioxanone Suture, Sterile Buttons, and Wound Vac-Assisted Closure

“…There are various documented methods of heel pad primary repair including K-wire or Schanz pin fixation as well as salvage with split-thickness skin grafting 1-4 . In addition, there is one case report of successful heel pad repair using suture and sterile button fixation by Kelly et al in a pediatric patient 5 .…”

“…The use of a quilted technique with suture that is passed through the skin, periosteum, and bone allows for a strong anchor to which sterile buttons may be affixed over the top. The sterile buttons allow for a greater surface area at the suture skin interface, which then disperses the force across the heel pad 5 . In this report, sterile buttons were used to affix the heel pad to the calcaneus; however, other cadaveric studies have demonstrated effective use of sterile buttons for fixation of flexor digitorum profundus repair.…”

“…PDS = polydioxanone suture. report of successful heel pad repair using suture and sterile button fixation by Kelly et al in a pediatric patient 5 .…”

“…Previous reports have associated simple suture fixation with increased wound pressure, decreased blood flow to the skin, and resultant tissue necrosis. These adverse associations have traditionally directed definitive treatment of heel pad injuries away from suture repair; however, there is one novel case report of successful heel pad repair using suture button fixation in a pediatric patient by Kelly et al 5 . The aim of this report was to demonstrate the successful use of this technique in an adult patient.…”