Sinus?

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I wonder if anyone could confirm whether I'm on the right lines here?

My patient is a 52yr old male with an ulcer underneath the first toenail of three months duration. He's a keen gardener, and the case history suggests there was trauma to the apex of the toe from his footwear. He has well controlled hypertension, but no other health problems.

Another colleague has been dressing the ulcer and discharged the patient 2 weeks ago as it had healed. Unfortunately, he came back as it has broken down again.
The ulcer has a healthy, granulating base and is 2 x 2mm in diameter and approximately 3mm deep. It exudes what appears to be synovial fluid. I will arrange for an x-ray this week as I suspect I'm dealing with a sinus that's tracking to the joint.

Could anyone suggest any other investigations that I need to arrange and what dressing regime you would recommend?

 

Hi Footman,

Can you confirm that it was a subungual ulceration as opposed to a apical ulceration?
Have you managed to probe the ulcer?
Serous fluid can present like synovial fluid at times- have you considered this as a factor? If you are querying tracking, is there pain at the IPJ?

Just need some extra bits of info to kickstart the brain.