Nail surgery in a diabetic with possible PVD?

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I have a new patient who presented to my clinic with a nail spicule evident in the sulcus, slight ulceration at the medial border and a history of pvd. Do i proceed with nail surgery or wait for a vascular referral?

Laura

 

You have got to ask yourself, "why is there an ulcer in the sulci, why is it taking time to heal?"

If the circulation really is that bad, refer to the GP for urgent revasularisation referral. However, you may be able to take the spike out, without phenolisation.

Also, what are the blood sugars like? It would be essential for them to be kept under control NOW!

 

Is it possible to just remove the spike and file it first off? Pain should not be a problem so you may be able to really get in there. Then just do the wound care and keep the nail back.
I would also be considering the referral for vascular if it has not already been seen to
A bit more info on the patient may give a chance for some better answers.

Cheers

Nick M

 

Does this mean the patient has pvd, or has been revascularised in the past, im a bit confused as the title says possible pvd?

The vascular surgeons we work with are brilliant, but to help our cause we get as much info as we can first, i would probably do an ABPI (looking out for artificially high readings) or if you have access to transcutaneous oxygen give that a try.

If you get the Diabetic Foot Journal there is a good piece by Martin Fox who has just set up a role as a vascular podiatrist up north - worth a read

 

I strongly suggest that you refer this patient to a podiatric surgeon colleague (as well as the vascular team if you feel necessary). An incisional technique is much less risky than chemical ablation in cases of compromised arterial supply.

All the best

Bill Liggins

 

HI Laura

You havent given us much to go on, but are you sure you are looking at ulceration and not just hypergranulation tissue at the site of the nail spike?

While vascular status obviously needs to be investigated, nail surgery may be unneccessary if you could just palliate by removing the spike and seeing if it resolves.

Regards
CM

 

Hi Laura
If you don't have all that much experience in dealing with this aspect of podiatry, it would be worth asking a 2nd opinion from a colleague on your patch who specialises in diabetes. Podiatry Arena is an amazing resource, but in such cases it is invaluable to assess the pt 'hands on', have access to previous history, biochemistry records etc.

All the best

 

If there is ulceration in the sulcus it is likely due to the lake of blood flow as a result if the pvd and pressure from the nail. Evaluate the wound, if it is a true ulcer then the risk is greater than if it was hypergranulation. In-which case I would remove the spike in a non-invasive manor. Keep the nail away from the sulcus and treat the ulcer accordingly. It will be slow to heal, just monitor and treat for infection if it appears.

 

Hello Laura,
You say the patient has a history of PVD - please can you post your vascular assessment of the patient so that we can get an idea of how good or bad the vascular supply to your patient's toe is? Once this information is supplied, people can give a better answer to your question.

 

I agree with you, having worked in a Diabetic High Risk clinic with no Vascular Surgeon to refer to in the whole country, I found early excision of the spike (being the cause of the ulceration) the only solution. Good follow up, patient education and apposite wound care is essential. Everything depends on the severity of vascular problems, glycaemic control. If after thorough neurovascular assessment and medical history taking you are still not comfortable about removing the spike then refer (if you have that luxury!).