Shallow ulcer at plantar aspect of 1st PIPJ

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Hi

I have been seeing a patient for a few months now, he was originally referred for ulcers on both 1st PIPJ's (plantar). I have healed the left, the right is now very shallow but static, I just can't heal the last part.

The gentleman is in his 80's, ex diary farmer, he still goes down to the farm twice a day. No diabetes, but severe PVD, vascular system is awful, feet are bright pink or purple depending on the weather. Has current ulcers on posterior of both lower legs.

He has pes planus feet, fully compensated rearfoot. I have placed express orthotics in both his work boots, as that was all he could tolerate and used deflection padding for the hallux. It worked for the left but not so well for the right.

The wound itself is shallow, nice base, no infection, minimal callus, it does get macaerated, which I believe is due to being in boots for a long period and his leg ulcers sometimes weep. I've now got him wearing slippers at home and this has helped a bit.

I have completely emptied my box of tricks and would very much appreciate some new ideas.

Many Thanks
Esh

 

If he has "severe PVD" i would look at confirming this with a duplex scan and possibly an angiogram. This may lead to angioplasty or by pass surgery. With limited blood flow the chances of healing are low.

You could try more offloading, hyperbaric oxygen, oxpentifaline (trental) and or arginine (arginaid drink) an amino acid that improves healing

 

Maybe you also need to consider to limit the range of motion on the 1st PIPJ/MPJ in order to faciliate wound healing.
Try fan strapping technique (using Mefix or Hyperfix tape) with the suitable dressing.

Another type of dressing I would like to suggest is using Mepilex (molnlycke)

 

Hi Esh,

What about using an Air Cast to offload the forefoot? That would allow him to keep mobile.

Just a suggestion.
John

 

Hi,
I have work with many patients who have suffered with ulcers. Over the last 12 years I have found it is most important to determine what type of ulcer you are treating. Is it vascular or neurological? Once you have a clear idea of the cause then you can fine tune treatment. Treat the cause and the ulcer usually heals.

If you have satisfied yourself that the cause has been adequately addressed and healing does not occur, then you are missing something. Then look to other factors such as bacterial load in the wound, patient O2 levels, protien levels, or pt compliance. If I am at this stage then I usually swab the wound, x-ray for osteomylitis, and ask GP for u&e's with FBC. These results help focus your treatments.
Good luck Sean

 

Thank you for your replies. I have pretty much covered all the aspects you talked about. The wound is definately caused by pressure, and not helped by circulation. Whilst he's a lovely fella, he's a stubborn bugger, won't wear a darco boot, let alone an aircast.

No surgeon will touch him and he won't let them anyway!! He's been recently swabbed and came back negative for anything special!, did it again, same result.

I have taped and padded to my little hearts desire, anything else?? I have no where else to refer him too (footwise).

Cheers
Esh

 

As previous posters have said referral back to gp for referral on to vascular surgeon seems a must.
As for the 'paddings', if the 1st MPJ'S have adeqate ROM why not getting the windlass mechanism working!
Had a success story (yep even me) a pt with chronic plantar IPJ ulcers b/halluces and private pod had been padding (10 mm felt) all around the ulcer on the medial side of the foot. I suggested we try the windlass thingy and ripped out the padding replacing it with rearfoot varus and forefoot valgus wedges (5 mm felt) and 'bobs-your-uncle" resolution within 2 visits!!
Hope the word doesn't spread, absolutely RUIN my reputation!

 

Hi

Thanks for all the replies. I tought I would just update.I had tried all of the above, negative swab, has seen vascular surgeon recently etc etc.

I found out yesterday, patient is in hospital, loss of mobility, was found on floor unable to move, has been in hospital for a week, pretty much in bed or just sitting. All ulcers healed! Now just got to keep them that way.

Thanks for help

Esh

 

Wow, you can't argue with that! Good for you!

Rebecca

 

I would also be inclined to think of a darco boot or air cast to take the weight away from the area. Has he had a recent ABPI to ascertain how poor the circulation is in this foot?
Maybe this would be an indicator as to how well this will heal.

Just read now that they've healed through bedrest...well done hope it stays resolved.