help with ulcer

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Hi would like some help with this patient,first time poster here.
68 year old male who has Type 2 diabetes palpable pulses and reduced monofilament detection,good control HBA1c is 6.5.
Developed lesion two years ago seen by vascular surgeon last Summer who removed nail with some improvement, brown spot however remained,I thought this looked suspicious vascular surgeon and endocrinologist were unconcerned.
Footwear is an issue,shoes are shallow, orthotist addressing this with deeper toe box.
Lesion doesn't improve despite reduction of nail, my question is does patient need another nail avulsion with phenolisation this time or is it pressure related?
Hope pics are not too blurry
Thanks in advance for your help.

 

Hi,
Have you done an x-ray? Looks like a fair amount of bony deformity, could be an underlying osteomyelitis, or charcot changes in the 1st toe. Or, just that the shape of toe is leading to constant footwear pressure due to the shallow footwear you mentioned.

Hope you get it sorted

 

Hi sdelaney,
I would say that if you can't get it healed now, you certainly won't heal it after a tna with or without phenol.
I agree with the previous poster that there could be more going on here than meets the eye, and I would certainly suggest an x-ray for a start.

Good luck

Catfoot

 

Hi sdelaney

I agree an x-ray is required to rule out the foregoing and a sub ungual exostoses.
The pics are blurred but I notice there appears to be a fairly tight involution of the remaining nailplate which would appear to be embedded around the "ulcer" If that is so could the "ulcer" in fact be hypergranulaion??

The bolstering around the nail may suggest a candidal infection which could possibly weaken the tissue and retard healing.
Just a thought
Hope that helps
Cheers
D

 

Thanks to the people who replied,much appreciated.
The patient had an x ray last year but may need it repeated.
Anyone any ideas about the brown spot?
Siobhan

 

If you have had a dermatologists opiinion.... then get them to sort it, you cant be all to everything..let the specialists stand or fall perhaps???

Cheers
D

 

May l suggest you cover the foot and over the brown spot area apply red lipstick, put the shoe back on and ask the client to walk around the room, both directions, then remove the shoe and look inside for any lipstick marks at the end of the shoe.

It all reads like not a shallow toe box but rather a shoe that is too short.
l have seen this before and it may well be the same problem?

 

Good call
Cheers
D

 

Hi Sdelany

You mention nothing about the persons other history, medical or social. You draw our focus onto the diagnosis of diabetes but give us no idea of how he is controlling his diabetes, how long he has been diabetic. Is diabetes the cause of the problem? Is it even contributing to the problem? I am doubtful.

Even from this photograph I can see that the patient appears to have quite extensive OA changes in the 3 visible digits? Wouldn't this affect the detection of the monofilament? Would this affect his mobility, the mechanics of his foot and perhaps entire lower limb? Does he have OA changes elsewhere?

You mention his footwear - I assume you mean the footwear he presents with in the clinic. Has he brought along a sackful of his "other" footwear for you to examine? Does he ever wear safety footwear or walking boots?

You mention nothing about the patient's social history. What hobbies/interests does he have? Is he still working? Is he a keen walker? Does he social dance for exercise? What do you see when he walks around the clinic? Have you analysed his gait, transposed this into his footwear and his social activity?

Did the patient commence a new activity two years ago - could it tie in with new found freedom of retirement?

Sorry this is absolutely basic stuff and something the profession seems to be overlooking in favour of high risk issues.

It is a problem I see regularly with patients who wear safety shoes when they work in industry or when they dance their hearts away in retirement in dance shoes they've had for 40 years or walk the countryside in inappropriate footwear or fell walk or have been fell runners in the past.... Some present with a medical history, some don't.

Boots n all seems to have pointed you in the direction of the way to go as have the endocrinologist and the vascular surgeon. Trust your "other" Podiatric skills and work with the mechanical function of this patients foot and lower limb....look beyond diabetes. If you cannot, then refer on to a colleague in MSK.

GB

 

sdelaney

Some good advice from GB. Can I just ask if the patient has actually had the 4th and 5th toes amputated or is it just the picture? You dont mention this in the original post.

CM

 

My thoughts also were along the lines of "what about the last 2 digits?" or is it just the photo ??

FDCB

 

Sorry my photo taking skills need some work,other toes not in picture but are not amputated.
Thanks again for the help with this Ill keep you updated!

 

sdelaney

Thanks for your reply, that is a surprise. It would help greatly of you could submit another photo with the whole foot visible as it seems to me that for the toes to be out of the picture the foot must be quite out of alignment .This could be associated with the increased pressure on the hallux.

Regards

CM

 

....perhaps it would also be helpful for sdelaney to also provide a much more thorough presentation when seeking help from fellow colleagues on PodArena?

GB

 

George,thanks for your help with this, your questions set me thinking.
This is my first post and presentation. Just wondering are there any guidelines on the best way to present I did look for some pointers but was unable to find them on the forum.

I an seeing the patient tomorrow and will certainly post a full picture.
Again thanks to everyone who replied.

 

this may help -

Presenting patients for clinical advice thread

 

Hi SDelaney,

First of all you have received some sound advice from previous posters on this thread and I agree that a more detailed history would have helped sort some kind of thought process here.
The first thing to bear in mind is that common things are common and rare things are rare BUT we must have a high index of suspicion when we are met with atypical presentation.

This problem may indeed be a manifestation of a pressure issue but diagnostics is far from being 'very basic stuff' given the potential adverse outcome of missing something significant as a result of any sloppy thought process.

I would suggest applying a more systematic approach to reaching a differential diagnosis; the pathoetiology will be associated with one of the following...

Congenital, infectious, metabolic, traumatic, neoplastic, biomechanical, iatrogenic, drug related.

Hence the need for a more considered history!

However, what is striking about the pictures you posted is the ulcerated nail bed and a melanotic lesion at the apex of the toe. Which of the above possibilities would need rapid attention diagnostically? Neoplastic in my book. Therefore a reasonable course of action would seem to be to repeat the X-Ray and arrange a biopsy of the nail bed.

My point here is that whilst the likelihood of a simple pressure lesion may be higher... what would you do if this was a member of your family... always a fairly good way to focus the mind. If you can't access these services then find someone who can.

From personal experience I can tell you that these simple steps can make a big difference. What's the worse that can happen? I would urge you to rule out something important before considering the lipstick test!

Best wishes

Greg

 

Hi Greg,
Just curious as to why you wouldnt do the "Lipstick test"?

It costs nothing, it takes 5 min to do and yes a poor fitting shoe is important to rule out, as it is doing damage with every step and could be resolved very quickly.

Yes the other should be done, but whilst you wait results this should be ruled out.

Your saying leave him walking around for a week in a poor fitting(?) shoe doing more damage until you get results from more "important" tests are done?

To suggest one is more important than the other makes no sense at all.

 

Hi David,

On the face of it that's a fair comment. However, the point that I'm driving at here is to consider ruling out something more sinister at the diagnostic stage and to act upon it prior to considering worthwhile efforts to explore other avenues.

I am not saying that the 'test' referred to isn't worth carrying out... After all, relieving the pressure is an important consideration whatever the etiology. Thank you for the opportunity to clarify the point.

Best wishes
Greg

 

I think more new posters (and some not so new) would benefit from reading and applying this before they request opinions and advice. Be great if this could be incorporated in to the Homepage.

Cheers,
Bel

 

SDelaney, how did this go for you and the client?

 

biopsy to r/o neoplasm.

 

When I have a pt in adequate fitting footwear that continues to have distal
hallux pressures I always check to make sure the hallux extensors aren't being used to assist ankle dorsiflexion. Have patient dorsiflex the ankle and see if the
hallux overextends. You can also stop ankle dorsi by holding the dorsum of the foot and instructing the patient to try to dorsilfex. Again look for excessive hallux extension. If this extension is evident the best solution is a stretch top
(Pedors or OrthoFeet 525/825 are two styles) or bubble patch/big ball and ring
stretch. Often if you feel inside the shoe you can identify where the hallux is
pressing into the shoe. Often this is secondary to dropfoot or equinus.