t h e s u r g e on 9 ( 2 0 1 1 ) 2 9 5e2 9 7

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The Surgeon, Journal of the Royal Collegesof Surgeons of Edinburgh and Ireland

www.thesurgeon.net

Correspondence: Case report

A devastating complication of ‘skin popping’

Srinivasan Iyer, Padmanabhan Subramanian, Amit Pabari*

Heatherwood and Wexham Park Hospital NHS Trust, Wexham, Berkshire SL2 4HL, United Kingdom

a r t i c l e i n f o

Article history:

Received 20 July 2010

Received in revised form

19 August 2010

Accepted 23 August 2010

Available online 16 September 2010

* Corresponding author. Tel.: þ44 01753 633E-mail address: ajpabari@aol.com (A. Pab

1479-666X/$ e see front matter ª 2010 RoyalSurgeons in Ireland. Published by Elsevier Ldoi:10.1016/j.surge.2010.08.010

revealed marked periosteal reaction with changes consistent

with osteomyelitis (Fig. 2). Furthermore, an MRI scan of the

Broad spectrum intravenous antibiotics were commenced.

Sir,

We present the first reported case of fibula osteomyelitis as

a direct consequence of intravenous drug usage, requiring the

removal of a long bone to treat a complication of “skin

popping”. In addition, we stress the importance of the

involvement of a multidisciplinary team approach in treating

this group of patients, in order to attain a longterm favourable

outcome.

Case report

A 40-year-old gentleman presented with a 7-day history of

a painful ulcer over the lateral aspect of his right lower leg. He

was an intravenous drug user for the last 15 years and on

a methadone programme for the previous 12 months. He

admitted to the practice of “skin popping” (injecting drugs

subcutaneously) over his right leg as he had exhausted all of

the venous access sites. The ulcer had been present for the

last 2 years and he did not seek any medical attention as this

area was used as a “shooters patch” to inject illicit drugs.

Clinical examination revealed a 22 � 15 cm ulcer over the

lateral aspect of his right lower leg with a central area of

necrosis approximating 12� 8 cm (Fig. 1). The base of the ulcer

extended down to the fibula. Radiographic examination

000; fax: þ44 01753 63305ari).College of Surgeons of Ed

td. All rights reserved.

lower leg also suggested evidence of fibular osteomyelitis.

The patient was admitted under our care and underwent

routine laboratory studies including blood count, electrolyte

studies, and inflammatory markers. Initial treatment

comprised of surgical wound debridement under general

anaesthesia. Osteomyelitis of the underlying fibula was noted.

Microbiology cultures from the initial debridement revealed

Staphylococcus aureus and b-haemolytic Streptococcus. Due to

poor patient compliance and the history of intravenous drug

usage, a longterm intravenous line for antibiotics as an out-

patient for treatment of the osteomyelitis was deemed

unsuitable. On subsequent debridement, the osteomyelitic

part of the fibula was excised and application of Vacuum

Assisted Closure (V.A.C�) device. After an additional week of

intravenous antibiotics and V.A.C� therapy, a split thickness

skin graft was utilised to resurface the soft tissue defect. The

patient was discharged 5 days post-surgery following

successful take of the graft. At a 1-month review the graft

appeared healthy (Fig. 3) and the patient continued with drug

abstinence following successful enrolment into a drug with-

drawal programme. Repeat X-rays of the leg at this follow-up

confirmed no residual osteomyelitis (Fig. 4).

Discussion

An estimated 16 million people of the world population aged

15e64 years inject drugs regularly.1 Hospital presentations of

intravenous drug users to the surgical departments vary from

life threatening conditions like necrotising fasciitis and septic

deep venous thrombosis2 to chronic wounds that are

1.

inburgh (Scottish charity number SC005317) and Royal College of

Fig. 1 e A large ulcer over the lateral part of right lower leg

as a direct consequence of “skin popping” practice. The

base of the ulcer extended down to the fibula.

Fig. 2 e A “shooter’s patch” (arrow) leading to the

osteomyelitis of the underlying fibula.

Fig. 3 e A healthy skin graft over previous “shooter’s

patch” at 1-month follow-up.

t h e s u r g e on 9 ( 2 0 1 1 ) 2 9 5e2 9 7296

unmanageable in the community. The peripheral venous

access in this group of patients obliterates due to the acidic

nature of the injected solution that leads to sclerosis of the

recipient veins. The illicit drug users then resort to the prac-

tice of “skin popping” by injecting the drugs subdermally.

Subcutaneous abscess is the most common complication in

“skin poppers” which can lead to local ulceration. The gran-

ulation tissue on these ulcers is maintained and utilised as

a “shooter’s patch” in order to inject illicit drugs. These sites

Fig. 4 e Radiograph taken at 1-month follow-up

demonstrating excised fibula and no residual

osteomyelitis.

t h e s u r g e on 9 ( 2 0 1 1 ) 2 9 5e2 9 7 297

are easy to access and typically concealed with simple

clothing and usually involve the limbs, however, ulceration in

the breast and penis has also been reported.3,4

Osteomyelitis in intravenous drug users typically arise

from haematogenous seeding of bacteria and to date there

have been a few sporadic cases affecting the long bones.5�8 To

our knowledge, this is the first reported case of osteomyelitis

involving the fibula as a direct consequence of “skin popping”.

Furthermore, this report demonstrates that when thorough

surgical debridement of an infected bone is undertaken, rapid

healing of the affected tissue can be achieved, resulting in

a reduced stay in hospital and out-patient antibiotic require-

ment. A consequence of inadequate treatment of osteomye-

litis is a chronic non-healing wound with granulation tissue

which may tempt the intravenous drug users to re-use these

sites.

Reconstructive surgeons treating similar wounds should

be aware of the potential conflict of interests in getting the

wounds healed. Intravenous drug users may interfere with

healing wounds in order to maintain granulation tissue to

inject illicit drugs. Effective treatment of “shooter’s patch”

requires a multidisciplinary team approach. Enrolment into

a drug withdrawal programme and longterm behavioural

change are as crucial as short-term interventions that result

in immediate goals. Poor compliance from patients will jeop-

ardise any wound healing efforts made by the surgical team.

Sources of support or funding

No external source of support or funding was received for this

project by any of the authors.

r e f e r e n c e s

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2. Fah F, Zimmerli W, Jordi M, Schoenenberger RA. Septic deepvenous thrombosis in intravenous drug users. Swiss Med Wkly2002;132(27e28):386e92.

3. Alvi A, Ravichandran D. An unusual case of breast ulceration.Breast 2006;15(1):115e6.

4. White WB, Barrett S. Penile ulcer in heroin abuse: a case report.Cutis 1982;29(1):62e3. 69.

5. Tice AD. An unusual, nonhealing ulcer on the forearm. N Engl JMed 2002;347(21):1725e6.

6. Buckland A, Barton R, McCombe D. Upper limb morbidity asa direct consequence of intravenous drug abuse. Hand Surg2008;13(2):73e8.

7. Chandrasekar PH, Narula AP. Bone and joint infections inintravenous drug abusers. Rev Infect Dis 1986;8(6):904e11.

8. Gordon RJ, Lowy FD. Bacterial infections in drug users. N Engl JMed 2005;353(18):1945e54.