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Hi

I work in a small rural pod service, often sharing my patient treatments with the community nurses. We are currently sharing a patient with an ulcer located at the 3rd mtpj. When he first presented he had this large fairly shallow ulcer, it was infected and partially covered with callus. Over the past month it has been healing nicely, the patient has neuropathic feet and was not aware it was as bad as it was.

I have offloaded the area with orthoses and he has responded really well, there is no infection present now and the area is granulating nicely. I saw him again last Friday, it had been three weeks since his last appointment, and on the surface the wound is good, but I was able to probe a good 2-3cm proximally down his foot. The end feel was spongy, not able to feel bone/tendon etc.

I have not dealt with an ulcer like this, the nurses want to get it surgically debrided and pack the sinus. I may be wrong but this doesn't feel right to me, if it was infected then yes, at least to the debridement. With smaller sinus's or deep, clean wounds, I have been dressing with lyofoam/allyven, padding/orthoses if necessary and letting nature take it course (as long as in right direction). With this ulcer I feel I should be doing something more.

Any advice on further treatment would be great. Many Thanks

 

You need at X-Ray +- other imaging studies, you need to access if the sinus is tracking into the joint space, if the sinus is discharging synovial fluid, re swab to ensure infection is under control and consider a Cam walker or cast to further reduce pressure above what footwear and orthoses can offer. Look at other opions for dressing the wound eg: silver products or cadaximar iodine. And surgical debridement may also be an option as it does turn a chronic wound into an acute one.

 

Many thanks for reply.