Trench Foot Research Articles

Cold Environment-Associated Extremity Lesions or Severe Hypothermia Help Differentiate Between Frostbitten and Trench Foot (Immersion Foot).

Cold associated foot injuries, such as frostbite and trench foot (immersion foot) are relatively common in cold environments. The former is classified as a freezing cold injury, and the latter as a nonfreezing cold injury. Trench foot is sometimes misdiagnosed as frostbite, and rapid rewarming exacerbates the condition. This paper aims to help differentiate between frostbitten foot and trench foot. This study included patients with frostbitten foot or trench foot treated at our hospital between December 2005 and May 2023. The differences in sex, age, month of injury, conditions at the time of injury, injury distribution, foot lesion laterality, other complications upon arrival (finger frostbite, immersion hand, or hypothermia), and presence and distribution of sensory disturbance at discharge were noted among the groups. A total of 16 patients (14 men) with frostbitten foot and 3 patients (3 men) with trench foot were identified. Finger frostbite observed in nine and zero patients with frostbitten foot and trench foot, respectively; and severe hypothermia on arrival observed in five and zero patients with frostbitten foot and trench foot, respectively. Physical findings at the initial examination showed that the frostbitten feet were dry, and the lesions were distal and clearly demarcated, whereas feet with trench foot were wet, and the lesions covered the entire sole and were not clearly demarcated. Accurate differentiation between frostbitten foot and trench foot and appropriate initial treatment are important. The presence of finger frostbite, immersion hand or severe hypothermia may help to differentiate between frostbitten foot and trench foot.

Elucidation of the Role of TRPV1, VEGF-A, TXA2, Redox Homeostasis, and Inflammatory Cascades in Protection against Cold Injuries by Herbosomal-Loaded PEG-Poloxamer Topical Formulation.

High-altitude regions, cold deserts, permafrost regions, and the polar region have some of the severest cold conditions on earth and pose immense perils of cold injuries to exposed individuals. Accidental and unintended exposures to severe cold, either unintentionally or due to occupational risks, can greatly increase the risk of serious conditions including hypothermia, trench foot, and cold injuries like frostbite. Cold-induced vasoconstriction and intracellular/intravascular ice crystal formation lead to hypoxic conditions at the cellular level. The condition is exacerbated in individuals having inadequate and proper covering and layering, particularly when large area of the body are exposed to extremely cold environments. There is a paucity of preventive and therapeutic pharmacological modalities that have been explored for managing and treating cold injuries. Given this, an efficient modality that can potentiate the healing of frostbite was investigated by studying various complex pathophysiological changes that occur during severe cold injuries. In the current research, we report the effectiveness and healing properties of a standardized formulation, i.e., a herbosomal-loaded PEG-poloxamer topical formulation (n-HPTF), on frostbite. The intricate mechanistic pathways modulated by the novel formulation have been elucidated by studying the pathophysiological sequelae that occur following severe cold exposures leading to frostbite. The results indicate that n-HPTF ameliorates the outcome of frostbite, as it activates positive sensory nerves widely distributed in the epidermis transient receptor potential vanilloid 1 (TRPV1), significantly (p < 0.05) upregulates cytokeratin-14, promotes angiogenesis (VEGF-A), prominently represses the expression of thromboxane formation (TXA2), and significantly (p < 0.05) restores levels of enzymatic (glutathione reductase, superoxide dismutase, and catalase) and nonenzymatic antioxidants (glutathione). Additionally, n-HPTF attenuates oxidative stress and the expression of inflammatory proteins PGF-2α, NFκB-p65, TNF-α, IL-6, IL-1β, malondialdehyde (MDA), advanced oxidative protein products (AOPP), and protein carbonylation (PCO). Masson's Trichrome staining showed that n-HPTF stimulates cellular proliferation, and increases collagen fiber deposition, which significantly (p < 0.05) promotes the healing of frostbitten tissue, as compared to control. We conclude that protection against severe cold injuries by n-HPTF is mediated via modulation of pathways involving TRPV1, VEGF-A, TXA2, redox homeostasis, and inflammatory cascades. The study is likely to have widespread implications for the prophylaxis and management of moderate-to-severe frostbite conditions.

Sterile necrotizing cellulitis in boat immigrants’ limbs after long journeys across the ocean

BackgroundIn the past few years, the Canary Islands received immigrants from sub-Saharan countries that arrive to the coast after long boat trips in extreme adverse conditions.The named “trench foot” is a previously described infectious entity developed after feet wounds that get infected by being in contact with water, urine and excrements in these small and crowded boats.We describe a new clinical entity, not published yet, that consists in massive edema in the extremities associating necrosis of the skin and subcutaneous tissue that characteristically respects the muscle and with a non-infectious etiology. Material and methodsA Database including 86 patients arrived by boat (“patera”) from sub-Saharan countries from September 2020 to January 2022 was made and 39 qualitative and quantitative items were analyzed. The Research Unit performed an observational prospective statistical analysis. ResultsA total of 16 patients developed the entity described as necrotizing cellulitis. Its physiopatology completely differs from the one described in the trench foot, since all the cultures resulted sterile. ConclusionsWe postulate an inflammatory theory due to the osmotic effect from ingesting sea water and/or the aggressive fluid reposition when they arrive to the emergency room with severe dehydration and hypernatremia. Early surgical evacuation of the edema with escharotomies incisions alleviate the symptoms and prevents progression of the disorder.

Celulitis necrosante estéril en las extremidades de migrantes marinos tras travesías prolongadas

BackgroundIn the past few years, the Canary Islands received immigrants from sub-Saharan countries that arrive to the coast after long boat trips in extreme adverse conditions.The named «trench foot» is a previously described infectious entity developed after feet wounds that get infected by being in contact with water, urine and excrements in these small and crowded boats.We describe a new clinical entity, not published yet, that consists in massive edema in the extremities associating necrosis of the skin and subcutaneous tissue that characteristically respects the muscle and with a non-infectious etiology. Material and methodsA database including 86 patients arrived by boat («patera») from sub-Saharan countries from September 2020 to January 2022 was made and 39 qualitative and quantitative items were analyzed. The Research Unit performed an observational prospective statistical analysis. ResultsA total of 16 patients developed the entity described as necrotizing cellulitis. Its physiopathology completely differs from the one described in the trench foot, since all the cultures resulted sterile. ConclusionsWe postulate an inflammatory theory due to the osmotic effect from ingesting sea water and/or the aggressive fluid reposition when they arrive to the emergency room with severe dehydration and hypernatremia. Early surgical evacuation of the edema with escharotomies incisions alleviate the symptoms and prevents progression of the disorder.

Trench foot and other non-freezing cold injuries (literature review)

Non-freezing cold injury is a general term that includes trench foot and immersion foot and is characterized by damage to the soft tissues, nerves, and vessels of the distal extremities as a result of long stay (usually two to three days or longer) in wet, cold (but not freezing: typically 0 to 15 °C) conditions. Trench foot syndrome primarily affects military personnel, fishermen, agricultural workers, travelers, and other segments of the population. In wartime, the number of such local cold injuries increases several times. Unfortunately, in domestic medical developments, this problem is practically not given due attention. Based on data from foreign literary sources and their own clinical experience, the authors were able to highlight the main patterns of pathogenesis and clinical picture of this pathological condition with justification of treatment tactic and preventive measures.

“Trench Foot” on the Banks of Lake Geneva: A Severe Case of Nonfreezing Cold Injury

Formerly known as “trench foot” or “immersion foot,” nonfreezing cold injury (NFCI) is a rare condition mainly seen among vulnerable groups. We report the case of a homeless male diagnosed with NFCI after having spent 2 days in rainy, cold weather. He presented with white, wrinkled feet and sensorimotor loss. Imaging revealed thrombosis of the leg arteries. No revascularization procedure was possible, and the patient developed soft tissue necrosis requiring bilateral transtibial amputation. Our case highlights the high morbidity linked with NFCI and the need for early recognition and treatment by medical health professionals along with the implementation of preventive measures.

Contact allergy mimicking trench foot infection: a case study

Hard-to-heal wounds are a major cause of morbidity and/or mortality. Multiple aetiologies can be identified and wounds can be treated according to their aetiology and macroscopic appearance. However, evidence behind the wide range of locally applied treatments is weak, without clear guidelines available to treat a variety of wound aetiologies. We present the case of a 63-year-old male with hard-to-heal wounds not responding to standard topical treatment. No clear underlying aetiology could be found. Extensive contact allergies were diagnosed after multiple topical and systemic treatments had been applied. A full recovery was observed after stopping topical agents and treating the wounds with an alternative treatment based on epicutaneous test results.

Hypothermia and Cold Injury in Children.

Hypothermia and Cold Injury in Children.

1479 Trench Foot: A Rare and Unusual Presentation of a World War I Disease

Abstract Introduction 'Trench foot' is a serious disorder of the lower limb, involving damage to the skin, nerves, and muscle, previously described in World War I soldiers during trench warfare. We present a rare and unusual case of ‘trench foot' sustained at home in a 20-year-old female. Case Report A 20-year-old woman presented to the Plastic Surgery department with pain and numbness affecting both feet, following failed trials of antibiotics. She managed her symptoms at home by immersing her feet in ice baths for 18-23 hours per day. She was tachycardic with raised inflammatory markers. Examination revealed breakdown of the skin bilaterally, with full thickness eschar. MRI showed extensive subcutaneous oedema and myositis. Initial surgical plan consisted of antibiotics and debridement of necrotic tissue with a view to grafting the skin later. Intra-operative findings included necrosis of the subcutaneous tissues and muscles. The patient deteriorated post-operatively with sepsis and underwent urgent Guillotine-style bilateral amputations. She was discharged home 18 days later. Discussion 'Trench foot' can be mistaken for soft tissue infections or frostbite. It is attributed to vasoconstriction followed by neurovascular changes and repeated cycles of thawing and freezing, acquired above freezing temperatures, unlike frostbite which occurs below freezing temperatures. The patient was initially reviewed by non-specialist teams without a clear diagnosis and sustained more pervasive tissue destruction than was originally apparent on examination. Prevention remains the best cure for ‘trench foot'. It is therefore important to familiarise ourselves with this rare disease. Where prevention or early detection is not possible, amputation can reduce the morbidity and mortality of the ensuing sepsis.

Nonfreezing Cold Injury (Trench Foot).

Nonfreezing cold injury (NFCI) is a modern term for trench foot or immersion foot. Moisture is required to produce a NFCI. NFCI seldom, if ever, results in loss of tissue unless there is also pressure necrosis or infection. Much of the published material regarding management of NFCIs has been erroneously borrowed from the literature on warm water immersion injuries. NFCI is a clinical diagnosis. Most patients with NFCI have a history of losing feeling for at least 30 min and having pain or abnormal sensation on rewarming. Limbs with NFCI usually pass through four ‘stages.’ cold exposure, post-exposure (prehyperaemic), hyperaemic, and posthyperaemic. Limbs with NFCI should be cooled gradually and kept cool. Amitriptyline is likely the most effective medication for pain relief. If prolonged exposure to wet, cold conditions cannot be avoided, the most effective measures to prevent NFCI are to stay active, wear adequate clothing, stay well-nourished, and change into dry socks at least daily.

Cutaneous Cold Weather Injuries in the US Military.

Service members of the US Military are at risk for cutaneous cold weather injuries due to the demands of military training, combat operations, and peacekeeping missions. In this article, we review common cutaneous cold weather injuries likely to be encountered in the military, including frostbite, immersion foot, pernio, Raynaud phenomenon (RP), and cold urticaria. We aim to bring awareness to these specific injuries to improve diagnostic and treatment outcomes, both in service members and civilians.

Getting Cold Feet in the First World War: Leaky Boots, Trench Foot and Vernacular Medicine Among British Soldiers

Summary During the First World War, trench warfare spurred the onset of various medical conditions. Yet, when soldiers fell ill, it was not immediately recognised that some maladies stemmed from contamination—soiling, infestation and poisons—in their uniforms. With a new focus on preventive medicine, doctors and medical scientists investigated numerous medical conditions that spread through contaminated uniforms. It is well known that these medical professionals developed a body of knowledge on the prevention of uniform contamination. It is far less known that soldiers also developed a set of medical ideas. Different ‘systems of medical ideas’ developed simultaneously during the Great War, and this is demonstrated through the study of trench foot. This article employs soldiers’ voices not only to highlight their reliance on vernacular medicine in the trenches but also to reformulate the boundaries of medical practice and ask who can be considered a medical practitioner.

Cold weather injuries among patients at an urban safety net hospital, Boston, MA

Background: Disadvantaged urban populations, particularly low-income and homeless individuals, are vulnerable to negative health effects from extreme weather exposure. Cold weather exposures and injury among these populations have received limited attention. We characterized incidence and risk factors for cold weather injuries (CWIs) among patients at Boston Medical Center (BMC), an urban safety-net hospital, over a ten year period.Methods: A case-control study was conducted using BMC emergency department (ED) records. Cases included all patients who presented to the ED from November 1, 2005, to March 31, 2015, with ICD-9/10 codes reflecting injury from exposure to extreme cold weather (e.g. hypothermia, trench foot, frostbite, chilblains). Incidence of CWI by month and year were calculated and stratified by sex, age, and race. Conditional multivariable logistic regression was used to identify risk factors for CWI, including race/ethnicity, homelessness, and mental and physical health comorbidities.Results: Incidence of CWIs from 2005-2015 was 1.2 cases per 1,000 persons (n=817 cases). January had the highest monthly incidence of cold-weather injuries (n=22±15). Cases were predominantly male (n=614; 75%), and approximately 44% were African American. Twenty-eight percent of cases had ≥2 CWI admissions. In multivariable analyses, non-white Hispanic/Latinos experienced 2.0x the odds of CWI compared to others (OR: 2.0, 1.3, 3.1; p=0.002). Homelessness was associated with reduced odds of CWI (OR: 0.05; 0.03, 0.08; p=&lt;0.001.) Comorbid mental health conditions and substance abuse were not associated with increased odds of CWI. Conclusions: Increased CWI risk among Hispanic/Latinos may reflect language barriers to accessing prevention. Reduced risk among persons experiencing homelessness may indicate that service providers in Boston are protecting at-risk individuals, or that such injuries are underreported. CWIs should be further assessed among marginalized urban populations.

Mechanical, compositional, and microstructural changes caused by human skin maceration

We quantify the effects of prolonged exposure to water on the mechanical, compositional and structural degradation of human skin. This environmental exposure is associated with maceration and the pathogenesis of dermatitis, immersion foot syndrome, and trench foot. Uniaxial tensometry reveals that water immersion of isolated stratum corneum (SC) ranging in age across 27 to 87 years can notably stiffen the tissue and cause both reductions in plasticity and rupture energy when allowed to equilibrate to a high relative humidity. Subsequent water sorption studies reveal that water immersion induced decreases in plastic extensibility are caused by a reduction in the tissue’s ability to hold water. In turn, this retention decrease is caused by a depletion in both lipids and natural moisturising factors. Further scrutiny of SC mechanical properties further reveals a clear delineation around 70 years. Employing this age-based categorisation, we establish that the degradative impact of water immersion is greatest for SC aged over 70 years. Histological examinations of full-thickness skin further reveal that prolonged water immersion for 7 days causes epidermal delamination, SC cavitation, and degradation in dermal collagen integrity. Immersion of skin in water at colder temperatures however reduces this degradation.

Skin diseases in displaced populations: a review of contributing factors, challenges, and approaches to care.

There are 70.8 million persons displaced worldwide due to war, persecution, and violence. Eighty percent of displaced persons reside in low- and middle-income countries with limited healthcare resources. Cutaneous diseases are commonly reported among displaced persons owing to numerous interrelated factors such as inadequate housing, overcrowding, food insecurity, environmental exposures, violence including torture, and breakdown of healthcare infrastructure. Diagnosis and management of these conditions, as well as an understanding of the context in which they present, is crucial to providing dermatologic care for displaced populations worldwide. Herein, we define displaced populations and, within this context, review the epidemiology of skin diseases, discuss pertinent skin conditions, examine challenges to care provision, and present approaches for improving dermatologic care. Inflammatory and communicable infectious disorders are the most common skin diseases seen in displaced populations. Other relevant conditions include skin manifestations of heat injuries, cold injuries, immersion foot syndromes, macronutrient and micronutrient deficiencies, torture, and sexual and gender-based violence. Provision of dermatologic care to displaced populations is hampered by limited diagnostic and therapeutic resources and specialist expertise. Medical screening for cutaneous disorders, context-relevant dermatology training, and telemedicine are potential tools to improve diagnosis and management of skin diseases in displaced populations.

My Feet Are Killing Me: A Hiker’s Journey

My Feet Are Killing Me: A Hiker’s Journey

Primary Erythromelalgia Complicated by Cellulitis: A Case Report and Review of Literature

Erythromelalgia is a rare disease with increasing incidence. It manifests as episodic painful red extremities triggered by heat. External cooling provides temporary symptomatic relief but may lead to complications such as cellulitis. Management includes trigger control, behavioral therapy and pain management. A 47-year-old African American male presented to the hospital with worsening bilateral lower extremity pain for three months. It was episodic, triggered by running and associated with erythema and swelling. Patient used cold water immersion and air conditioning for pain relief. One week prior to presentation, he developed painful blisters on his feet. On presentation, vital signs were stable, patient was afebrile. Acute infection was ruled out and he was discharged with outpatient rheumatology follow up for erythromelalgia. He returned one week later with worsening symptoms. CT scan of lower extremities indicated bilateral cellulitis. Patient was managed by medicine, dermatology, rheumatology, and podiatry for cellulitis, fungal infection, trench foot and primary erythromelalgia with antibiotics, antifungals, gabapentinoids and behavioral therapy. His infection resolved and pain improved. He was discharged with outpatient rheumatology follow up. Erythromelalgia is a highly debilitating disease with episodes of burning erythematous extremities triggered by increase in skin temperature. Patients seek pain relief by excessive external cooling. Pathophysiology involves gain of function mutation in voltage gated sodium channels causing autoregulatory dysfunction of skin. Underlying disease mechanisms are ambiguous and may involve unidentified genetic components and unknown triggers. It is a clinical diagnosis. Therapy requires a multidisciplinary approach. Complications should be promptly addressed given attention next to symptomatic relief. There is a lack of disease specific treatment and complete remission is unlikely. Our patient responded well to gabapentinoids and behavioral therapy.

The Use of High-Risk Criteria to Assess Mortality Risk among Unsheltered Homeless Persons.

We assessed the ability of high-risk criteria developed by Boston Health Care for the Homeless Program to identify increased mortality during a 10-year cohort study (January 2000-December 2009) of 445 unsheltered adults. To qualify as high-risk for mortality, an individual slept unsheltered for six consecutive months or longer plus had one or more of the following characteristics: tri-morbidity, defined as co-occurring medical, psychiatric, and addiction diagnoses; one or more inpatient or respite admissions; three or more emergency department visits; 60 years old or older; HIV/AIDS; cirrhosis; renal failure; frostbite, hypothermia, or immersion foot. A total of 119 (26.7%) individuals met the high-risk criteria. The remaining 326 individuals in the cohort were considered lowerrisk. During the study, 134 deaths occurred; 52 (38.8%) were among high-risk individuals. Compared with sheltered individuals, the age-standardized mortality ratio for the high-risk group was 4.0 (95% confidence interval 3.0, 5.2) times higher and for the lower-risk group was 2.2 (1.8, 2.8) times higher. The hazard ratio, a measure of survival, for the high-risk group was 1.7 (1.2, 2.4) times that of the lower-risk group. High-risk criteria predicted an increased likelihood of mortality among unsheltered individuals. The lower-risk group also had high mortality rates compared with sheltered individuals.

Socks at War: American Hand Knitters and Military Footwear Production for the World Wars

Abstract In both World Wars, combatant nations, including the United States, Britain, and Germany, learned that inadequate or poorly-maintained footwear produced costly and preventable casualties from trench foot and frostbite. While provision of shoes and boots to troops were major issues in earlier conflicts, no nation before World War I had fully appreciated the significance of warm, dry, well-fitting socks to the effectiveness of soldiers in the field. The large numbers of trench foot casualties in World War I, especially among the French and British, convinced policymakers that this vital commodity must receive a higher priority in military production planning, but few nations in wartime could shift production to knitting mills rapidly enough to make a difference. Thus, in Britain and the U.S, the best policy option proved to be recruiting women and children civilians to knit socks by hand for the military in the first war, and for refugees, prisoners and civilians in the second. This paper discusses the economic and military importance of this effort, including the numbers of pairs produced, and the program’s role in supplementing industrial production. The production of this low-technology but crucial item of military apparel is typical of detail-oriented tasks performed by women under conditions of full mobilization for war, in that they have a high impact on battlefield and home front performance and morale, but very low visibility as significant contributions to national defense. Often, both during and after the emergency, these efforts are ridiculed as trivial and/or wasteful. Unlike women pilots or industrial workers, handcrafters of essential supplies are regarded as performing extensions of their domestic roles as makers and caretakers of clothing and food. This was especially true in the U.S. in and after World War II, a wealthy industrialized nation that took pride in its modern - and thoroughly masculinist - military industrial complex.

Homeless Hope: a voluntary, nurse-led organisation working to educate and support people sleeping rough.

This article describes the development of a nurse-led voluntary organisation that provides basic foot care to the homeless at street level in three Welsh cities. There is a large percentage of street sleepers who choose not to access professional health and care services for various reasons, and many of these individuals have foot health problems, such as sore, painful, swollen feet from continuous walking, calluses, dried skin, blisters that are often de-roofed and trench foot. Through support and education, however, several of these people have been able to take ownership of their identified problems, by building trusting relationships with Homeless Hope nurses. Through collaborative communication with professional services, Homeless Hope nurses provide an informal link between non-engaging rough sleepers and the services in place to help support them.