Small Ulcer & Exposed Tendon! Treatment?

Members do not see these Ads. Sign Up.

Hi All,
Ive recently been treating a patient with a clawed 2nd toe on the R/F
This patient had a corn on the dorsum of the toe caused by the prominence of the joint
Ive manged to enucleate the corn & used one of those silicone pads cut from a strip
The Strip however has rolled down the toe and trapped under the clawed toe and caused an ulcer.The tendon is exposed and the site is odourous and the foot is noticeably warmer than the left so Im sure its infected
Ive advised the patient to get antibiotics but its proving a challenging task to get the site to heal.
Ive applied betadine,a dry secondary dressing along with TG & Mefix twice but the wound is not improving.I noticed the tendon was just slightly visible on the last visit.
Ive purchased some Amerigel which I will use in conjuntion with the antibiotics my patient receives from his GP.
Any suggestions from similar experiences as to what would be the best thing to do would be appreciated.Thank You

 

The first thing to do is to ascertain the nature of the infecting organism, so take a swab. The most likely candidate is Staph.Aureus, but you don't know this until you receive the result, so in the meantime Rx T.Flucloxacillin 500mg qds or T.Erythromycin 500mg qds if the patient is 'allergic' to penicillins (always assuming that there is no contra-indication in either case). The precise dressing, in my view, is largely irrelevant provided that the circulation is patent, but hydrocolloids such as 'second skin' are comfortable. When the ulcer is healed (or before if the defect is large), refer the patient to a Podiatric Surgeon colleague to reduce the clawing of the toe. Again, this is really a matter of addressing the underlying complaint. There may be a number of Podiatric Surgeons in the Manchester area but I do know of Lewis Stuttard who practices in Rochdale and who would, I am sure, be able to help.

All the best

Bill Liggins

 

If the tendon is exposed, you must assume that the bacteria have already tracked down the tendon to deeper layers, possibly bone. Therefore, I would treat this as osteomyelitis, until proven otherwise. I would take plain film x-rays, order either a bone scan or MRI and then refer to a podiatric or orthopedic surgeon who can decide if the tendon can be salvaged and to take a deeper culture. The patient will likely need to be on antibiotics for at least 4-6 weeks. And don't assume that just because the skin has healed that the infection has cleared. Many cases of osteomyelitis can brew quite nicely under closed skin, slowly eroding the bone over time. I would error on the side of caution with this one.

 

I highlighted this because many practitioners in the UK don`t utilise the skills of our Pod surgeons in what is actually quite a simple procedure to address the cause. When we see breakdown of tissue in bony prominences time and again we should be exploring all the preventative measures.

Also agree with Kevin;

Whilst you don`t provide med history of this patient (so we can`t ascertain level of risk) we have to remember that pathogens spread from skin into deeper structures by secretion of enzymes and toxins along the planes of least resistance. i.e along the tendon. If the patient has DM you may find this useful;

Skin & Soft Tissue Infections - Diabetic Foot Ulcer
Take culture swabs if there is evidence of clinical infection such as increased pain, enlarging ulcer, cellulitis and pyrexia, then initiate empirical treatment. Consider risk factors for MRSA colonisation (recurrent abscesses/contact with military personnel/engages in contact sport). Consider referral for specialist opinion.

When to investigate;
Take culture swabs from cleaned base of ulcer if there is evidence of clinical infection. Alter treatment in response to culture and sensitivity results. Seek microbiological advice if colonised with MRSA.
Treatment choices First Line:
Flucloxacillin 500mg qds
PLUS
Amoxicillin 500mg tds
Review after 14 days
(Add Metronidazole 400mg tds if offensive)
If penicillin allergic or known to be colonised with
MRSA
Doxycycline 200mg stat then 100mg od. Review after 14
days.
(Add Metronidazole 400mg tds if offensive)

Cautions Clinical signs of infection may be masked in a person with diabetes and it important to have a low threshold for considering
antibiotic use, especially in someone with a neuro-ischaemic ulcer
Evidence Available evidence does not support treating clinically uninfected ulcers with antibiotics, but antibiotic therapy is indicated for
almost all infected wounds in conjunction with good wound care
References Clinical Knowledge Summaries Diabetic Foot Ulcers www.cks.library.nhs.uk accessed 31.3.08

Cheers,
Bel

 

Just a note of caution re: Kevin's otherwise good advice.

The situation may well be different in the States; however, in the U.K. you should refer to a Podiatric Surgeon colleague rather than to an Orthopaedic Surgeon. The current attacks on this profession from the Orthopaedic profession are such that they should be given no encouragement.

All the best

Bill

 

hlh494

With respect, if I am correct in assuming you are seeing this patient privately, I get the feeling that you are out of your comfort zone and should be referring this patient to the NHS for immediate treatment and resolution as they have the back up that may be necessary.

Cornmerchant

 

Precisely. the OP is in the Manchester area where I understand there a number of Podiatric Surgeons in the NHS, and, as I stated, the patient should be under the care of one of our colleagues.

Bill Liggins

 

Bill

I was thinking of the more immediate need for healing the ulcer which is better served in the NHS with full access to wound management team and their backup. Agreed long term that the problem needs to be addressed, however remember that it was the choice of protective device that caused the ulcer in the first place. Chances are that the patient does not need surgery- many patients l know live quite happily with clawed toes.

regards CM

 

In an ideal world I would agree. However, I am treating an increasing amount of pts (including those with DM) in private practice for recurring apical, ID, PIPJ breakdown as there just isn`t this wonderful `NHS wound management team` available to regularly debride and offload these lesions. The last one I referred directly to NHS podiatry (with a copy of the referral letter to their GP), for regular treatment of a chronic ulcer, was seen by the practice nurse who said "I`m sorry I dont know how to deal with this":bang:. After 2 visits the pt was so annoyed she said she would rather pay me a full fee for weekly tx!

Maybe not, but surely that is the patients` call, not ours? Many are not even aware that toe straightening is an option.

Cheers,
Bel

 

Thank you Bel. I am weary of politics. However, I was outlining a way the OP could refer in directly to a colleague in the NHS for surgical treatment or for other treatment as appropriate. However, if others wish to send to the GP, who as you point out, may or may not refer to the diabetologist or other specialist, who may or may not work with a pod, and who may or may not decide to send on anyway, is really a matter for them. I do feel that we pps have a huge opportunity which will arise from the new commissioning system, but until they can learn the lessons learned years ago by the medical profession regarding referral systems, nothing will happen. :bang:

All the best

Bill

 

Bel

I think there is a difference between the breakdowns that we all see regualarly and the sudden appearence of a tendon! The OP is obviously struggling and out of their depth hence the advice to refer on.

Did I say anywhere that I dont inform the patients of "choices" ?

CM

 

Evening CM,

That`s quite an assumption to say they are out of their depth, the OP does not provide enough information to arrive at that conclusion. Incidentally, I am seeing another pt tomorrow with a history of HM on her 4th digit and subsequent ulceration. I first saw her 2 weeks ago with, you guessed it, exposed tendon. Does she want to be seen by the practice nurse, who just splashed betadine on the ulcer last time she went to her GP because she didn`t qualify for NHS podiatry? No, she`d rather pay my dom fee (which is not cheap) every week until the lesion heals.... And so it goes on as Bill described. Who do you recommend the OP refer on to, if not a pod surgeon? "Chances are" the pt would not fulfill the ever stringent criteria of NHS podiatry.

Erm, no you didn`t. Nor did anyone accuse of you of not informing the pts of choices. I said;

Note; `ours` not `yours`.

Cheers,
Bel

PS sorry to be a tad whingy today....my week is not going well and it`s only Tuesday:boohoo:

 

Use of Betadine on an openwound or ulcer is not recommended. Its use is limited to intact skin antiseptic application.

 

I know

 

Just to clarify; I am sure that Bel was making the point that although you know, and I know, and she knows, the practice nurse did not know. (It is therefore better to ref. to a colleague than to the GP and then on to the NHS as was suggested elsewhere).

All the best

Bill

 

yep, what Bill said.