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a b c

d e f
Figure 2: (a) Crush injury right leg and foot with heel pad avulsed skin and subcutaneous tissue connectivity in the proximal and distal part; (b) X‑ray
lateral view right foot showing K‑wires used for stabilization of avulsed heel pad; (c) appearance of foot 3 weeks following debridement and hyperbaric
oxygen treatment session; (d) plantar view of foot following 3 weeks; (e) medial view of the foot following skin grafting; (f) plantar view of the foot
following skin grafting

a b

c d
Figure 3: (a) Heel pad avulsion based distally‑medial view of left foot Figure 4: Diagram illustrating heel pad tissue degloved as a bucket
foot; (b) wound debridement and primary suturing after placing a handle type over the calcaneal bone with continuity proximally and
suction drain; (c) picture presenting the wound status during immediate distally with disruption of soft tissue medial and lateral aspect
postoperative period; (d) late postoperative picture

only a soft tissue bridge anteriorly. In some instances, the management of such complicated injuries [Figure 5].
the heel pad tissue is degloved in a “bucket handle” Out of 6 angiosomes of the foot and ankle, 3 angiosomes
configuration over the calcaneal bone, with continuity are supplied by the posterior tibial artery, 2 angiosomes
proximally and distally and disruption of the soft tissue are supplied by the peroneal artery, and 1 angiosome is
[4]
in the medial and lateral aspects [Figure 4]. The heel pad supplied by the anterior tibial artery. The calcaneal branch
tissue, with its unique architecture, demands preservation of the posterior tibial artery supplies the medial aspect of
in cases of any possible vascular supply. Premature efforts the ankle and the plantar aspect of the heel pad region. The
to remove doubtful tissue may result in loss of valuable medial plantar branch of the posterior tibial artery feeds
sensate heel pad tissue, which might have been preserved the medial aspect of the plantar instep. The lateral plantar
by delayed intervention. However, a delayed intervention branch of the posterior tibial artery feeds the lateral aspect
may also result in decreased survival rates of local or of the forefoot, the plantar aspect of the midfoot, and the
distant tissue transfer secondary to tissue edema and an plantar aspect of the forefoot. The calcaneal branch of the
increase in inflammatory factors. Since the zone of soft peroneal artery supplies the lateral aspect of the heel pad
tissue compromise may extend beyond the zone of injury region. Taylor et al. found that these angiosomes are
[5]
[4]
of the foot, reconstruction of heel pad with local or distant interconnected by either reduced caliber choke vessels
soft tissue reconstruction can be challenging. In addition, or by anastomotic arteries. The principle of utilizing
efforts to replace the heel pad with vascularized or HBO therapy for ulcers with vascular insufficiency and in
regional flaps may be limited by decreased fine sensation, radiation‑induced wounds can be applied to the salvage of
bulky soft tissues, and alteration in gait function. [3]
vital heel pad tissue. HBO therapy creates an increase in
The vascular anatomy of the leg and foot by means of the dissolved oxygen in the plasma where there is increased
angiosomal concept provides us with a better approach for partial pressure of arterial oxygen. Oxygen delivery through

Plast Aesthet Res || Vol 2 || Issue 2 || Mar 13, 2015 59