Trench Foot


Article Author:
Jeffrey Bush


Article Editor:
Simon Watson


Editors In Chief:
Sebastiano Cassaro
Joseph Lee
Tanya Egodage


Managing Editors:
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Frank Smeeks
Kristina Soman-Faulkner
Benjamin Eovaldi
Radia Jamil
Sobhan Daneshfar
Pritesh Sheth
Hassam Zulfiqar
Steve Bhimji
John Shell
Matthew Varacallo
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Hajira Basit
Phillip Hynes
Kavin Sugumar


Updated:
2/20/2019 12:51:13 PM

Introduction

Trench foot is one of three subclasses of immersion foot, differentiated by the temperature of the exposure, and is caused by prolonged exposure to cold but usually not freezing, damp, and sometimes unsanitary conditions. The condition will ultimately cause skin and tissue breakdown which increases the risk of infection and raises the morbidity and mortality.[1][2][3]

Etiology

Many soldiers during World War I had trench foot. Starting in 1914, trench warfare was a common strategy on the European front. During this time, the soldiers found themselves standing in waterlogged trenches at the front for long periods of time and were subjected to wet, cold, and muddy conditions. In the winter between 1914 and 1915, it is reported that over 20,000 British troops were treated for trench foot.  Furthermore, it is estimated that trench foot contributed to the deaths of 2000 American and roughly 75,000 British soldiers. Interestingly, trench foot was first described in 1812 while Napoleon’s army was retreating from Russia. Dr. Dominique Jean Larrey, a French army surgeon, was the first clinician to describe the condition. Although the prevention of trench foot is relatively straightforward and widely known, as recently as 1982, the British Army dealt with the condition during the Falklands War.[4][5][6]

Epidemiology

Recently, clusters of cases have been described in the civilian population during large, multi-day, music festivals where the conditions are conducive to causing the disease. In everyday clinical practice, the homeless population is also susceptible to trench foot due to lack of shelter and prolonged exposure to moist and cold environments.

Pathophysiology

Unlike frostbite, trench foot can occur without freezing temperatures. The feet can be affected in temperatures up to 16 C (60 F), and the disease can develop in as little as 10 to 14 hours. With the addition of moisture to the above environmental conditions, destruction and deterioration of the capillaries can lead to degradation of the surrounding tissue. Hyperhidrosis (excessive sweating) can also be a contributing factor to the development of trench foot.

History and Physical

Trench foot often begins with a tingling, itching and/or numb sensation. Due to the poor blood supply, the feet may become erythematous or cyanotic, and they may have an odor of decay if necrosis has started to set in. Significant swelling can occur, and there are some descriptions that the feet can double in size due to the edema. The disease has been known to affect just the heels or toes, but most commonly, it involves the entire foot. Some patients have described an itching or tingling sensation while others have described a prickly feeling and a heaviness to the feet. The skin can appear blotchy, and as the disease progresses, blisters and open sores can occur which can lead to fungal as well as bacterial infections. As the disease continues to advance, skin and tissue may slough off.  If the condition is left untreated, gangrene can set in. At this point, amputation may be needed to avoid further progression of the disease and other complications such as sepsis and death. When trench foot is identified and treated early, complete recovery is expected; although, there can be a significant amount of temporary pain when sensation returns to the affected area.

Evaluation

The diagnosis of trench foot is entirely clinical. One must first identify the situations where it occurs, and a good physical examination is paramount. Underlying infections must be ruled out so a white blood cell count might be indicated. Inflammatory markers such as a C-reactive protein (CRP) or erythrocyte sedimentation rate might prove helpful, as will a radiograph or bone scan if underlying osteomyelitis is suspected.

Treatment / Management

By keeping the feet warm, dry, and clean, trench foot can be avoided. During World War I, the institution of regular foot inspections was found to decrease the incidence of the disease. The soldiers were paired up and were instructed to watch the feet of their partner. It was found that a soldier was more likely to remove his boots and dry his socks and feet if he was reminded to do so by his fellow soldier. After thousands of cases were seen, soldiers were ordered to have 3 pairs of socks with them at all times and were told to change rotate the pairs at least twice a day.   Whale oil was also provided to the soldiers to rub on their feet after they were dry to help prevent trench foot. Historically, a battalion (up to 1000 men) at the front in World War I, could use up to 10 gallons of whale oil on any given day. To help prevent trench foot, wooden boards, known as duckboards, were used to cover the wet, muddy, cold ground in the trenches. Troop rotation was also used to limit an individual soldier’s exposure. As World War I progressed, the incidence of the disease declined due to the measures mentioned above.[7][5][8]

The best treatment for trench foot is prevention. Some of these methods are outlined above. It was critical that soldiers changed their socks frequently and made sure their feet were dry to avoid the condition. During World War I, as the understanding of the disease progressed, the treatment of trench foot also evolved. Early on, bedrest was recommended, and the application of numerous different agents was tried at one time or another. Among these included a mixture of lead and opium, alcohol of different types, mercuric chloride in alcohol, tincture of iodine, oil of wintergreen, picric acid, and chloral hydrate mixed with camphor. Some powders were also used including boric acid, starch, zinc, and salicylic acid. Radiant heat, complex methods of massage, and even different types of electrical stimulation were tried in treating trench foot when the initial treatments failed. However, once the disease progressed to a severe case, the mainstay of treatment was surgical, similar to the treatment of gangrene. Many times, the patient ended up with an amputation.[9]

Differential Diagnosis

A good history and physical should allow a clinician to differentiate trench foot from frostbite, cellulitis, and other localized processes.

Prognosis

Today, trench foot is usually identified early, and the treatment is very straightforward. Keeping the feet dry and warm is imperative. Rest and elevation of the affected foot are encouraged since this will help prevent new wounds and blisters. NSAIDS will help with any discomfort the patient is having and will also help to alleviate the swelling. If the patient cannot take NSAIDS, then acetaminophen or aspirin will help with the pain but may not help with the swelling. According to the Center for Disease Control and Prevention (CDC), the prevention and treatment of trench foot are straightforward, and their recommendations are as follows:

  • Take off socks
  • Avoid wearing dirty socks to bed
  • Wash the affected area right away 
  • Dry feet completely
  • Apply heat packs to the area for up to 5 minutes

If the above measures do not help the condition, then the CDC recommends further evaluation by a clinician.

Enhancing Healthcare Team Outcomes

Trench foot is usually managed by a multidisciplinary team that consists of an emergency department physician, nurse practitioner, vascular surgeon, internist, orthopedic surgeon and an internist. Once the diagnosis is clinically made, the treatment is urgent. The foot must be kept warm and dry. Many oils have been recommended to protect the skin and underlying tissues but no evidence supports the use of one treatment oil over another. If the foot is warm, talcum powder can be used. Radiant heat can be used to keep the foot warm. Since the skin is fragile, manipulation and massage should be avoided. The foot should be regularly assessed for infection and gangrene. Recovery occurs in most mild cases, but it is prolonged. In severe cases of trench foot, amputation may be the only option. [10](Level V)

 

 


Interested in Participating?

We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.

Improve Content - Become an Author or Editor

This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.

Trench Foot - Questions

Take a quiz of the questions on this article.

Take Quiz
Which of the following is not a characteristic of trench foot?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
According to the Center for Disease Control, which of the following interventions is not recommended in treating a mild case of trench foot?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Who is most likely to develop trench foot in today's society?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What is the most effective treatment in the later stages of trench foot?

(Move Mouse on Image to Enlarge)
  • Image 6028 Not availableImage 6028 Not available
    Contributed by Mehmet Karatay (CC by 3.0 https://creativecommons.org/licenses/by-sa/3.0/deed.fr)
Attributed To: Contributed by Mehmet Karatay (CC by 3.0 https://creativecommons.org/licenses/by-sa/3.0/deed.fr)



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 46-year-old homeless man presents complaining of bilateral foot pain. There have been rainstorms for the past week, and he has been unable to keep his feet dry. Luckily, the temperature has been hovering around 55 degrees. His feet are somewhat numb and slightly swollen and have patches of erythema and pallor. What is the most likely diagnosis?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 17-year old female presents to the emergency department complaining of bilateral foot pain. She had just spent 4 days at an outdoor music festival where the temperatures were hovering around 50 degrees. She describes a lot of mud as there were some rain showers throughout the festival. She has not changed her socks or shoes since her bag was stolen on the first day of the festival. Her feet are swollen, with patches of erythema and pallor and she describes a decrease in sensation in both feet. She is afebrile. What is the likely diagnosis?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up

Trench Foot - References

References

Proctor-Brown L,Hicks R,Colmer S,Guilfoyle D,Dallap-Schaer B,Johnson AL,Tomlinson J, Distal limb pathologic conditions in horses treated with sleeve-style digital cryotherapy (285 cases). Research in veterinary science. 2018 Dec;     [PubMed]
Hall A,Sexton J,Lynch B,Boecker F,Davis EP,Sturgill E,Steinmetz M,Shackelford S,Gurney J,Stockinger Z,King B, Frostbite and Immersion Foot Care. Military medicine. 2018 Sep 1;     [PubMed]
Schmidt D,Germano AMC,Milani TL, Effects of water immersion on sensitivity and plantar skin properties. Neuroscience letters. 2018 Nov 1;     [PubMed]
Gorjanc J,Morrison SA,McDonnell AC,Mekjavic IB, Koroška 8000 Himalayan expedition: digit responses to cold stress following ascent to Broadpeak (Pakistan, 8051 m). European journal of applied physiology. 2018 Aug;     [PubMed]
Anand P,Privitera R,Yiangou Y,Donatien P,Birch R,Misra P, Trench Foot or Non-Freezing Cold Injury As a Painful Vaso-Neuropathy: Clinical and Skin Biopsy Assessments. Frontiers in neurology. 2017;     [PubMed]
Forbes KE,Foster P, An unusual case of an immersion hand presentation in a military signaller operating in the jungle in Belize. Journal of the Royal Army Medical Corps. 2017 Dec;     [PubMed]
Cappaert TA,Stone JA,Castellani JW,Krause BA,Smith D,Stephens BA, National Athletic Trainers' Association position statement: environmental cold injuries. Journal of athletic training. 2008 Oct-Dec;     [PubMed]
Bennett BL,Holcomb JB, Battlefield Trauma-Induced Hypothermia: Transitioning the Preferred Method of Casualty Rewarming. Wilderness     [PubMed]
Johnston AM,Singleton J, Cold feet. BMJ (Clinical research ed.). 2016 Sep 5;     [PubMed]
DeGroot DW,Castellani JW,Williams JO,Amoroso PJ, Epidemiology of U.S. Army cold weather injuries, 1980-1999. Aviation, space, and environmental medicine. 2003 May;     [PubMed]

Disclaimer

The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of Surgery-General. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for Surgery-General, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in Surgery-General, you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of Surgery-General. When it is time for the Surgery-General board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study Surgery-General.