Management of Traumatic Injury to the Left Foot in a 48-Year-Old Man: A Case Report

TL;DR

A 48-year-old man with a left foot injury recovered fully through coordinated medical care, pain management, and workplace adjustments.

Contribution

This case highlights the effectiveness of multidisciplinary care in managing traumatic foot injuries and comorbidities.

Findings

Initial wound care and imaging ruled out fractures but identified persistent symptoms requiring follow-up.

Multidisciplinary care, including physiotherapy and workplace adaptations, enabled a full recovery.

Comorbid hyperlipidemia was detected and treated, improving overall patient outcomes.

Abstract

Approaches to foot injury care depend on a range of clinical steps that promote proper healing and function. We present a case of a 48-year-old plumber who injured his left foot when a metal object fell on it at home. Initial management involved irrigation, suturing, antibiotics, analgesia, and a plain foot X-ray, which was normal. Follow-up at the Occupational Health Unit (OHU) addressed persistent swelling, pain, and numbness. Further evaluation ruled out a fracture, but the patient required extended sick leave and restrictions on weight-bearing tasks. He received nonsteroidal anti-inflammatory drugs (NSAIDs), topical agents, vitamin supplements, and physiotherapy. Laboratory tests revealed elevated cholesterol, prompting statin therapy. Over four weeks, he progressed to resuming duties with restrictions. After seven weeks, continued monitoring by a multidisciplinary team supported his return to full duties without restrictions. This case illustrates the value of thorough wound care, tailored pain control, and coordinated care among multiple services. The prompt detection of comorbidities such as hyperlipidemia enabled early intervention. Ultimately, a stepwise combination of medical treatment, rehabilitation, and workplace adaptations restored the patient’s full function and ability to perform his usual work.

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