ulcerative heloma durum

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Hi everyone

This is my first post to Pod Arena so I hope this works!

I was hoping to get your opinion:

A 65 year old lady presented to me 3 months ago with a very painful 5th toe. It has been bothering her for several months. On examination I noticed a large heloma durum on the medial aspect of her 5th DIPJ. Slight surrounding redness was present and it was extremely tender to touch. No infection was present. She walks very heavily on the lateral aspect of her feet, wearing very tight/small enclosed runners that have increased pressure to the 5th.

I enucleated the heloma (which was very painful!) and a small amount of bleeding prevented me from seeing the base clearly. I did not feel it was fully enucleated however left it and asked for a review in one week. It was to be offloaded and redressed by my pt. I advised on the most suitable footwear to reduce pressure. I ordered an xray to look for abnormalities of the underlying condyle.

I didn't see her again for 5 weeks, and on return I carried out the same treatment. She had continued to wear the same footwear. The pain had increased and I advised her to return in one week for debridement under local anaesthetic and tornicot. This did not help relieve the pain either. I advised oral antibiotics, daily/twice daily dressing with medihoney and offloading.

My pt has an ulcer of approximately 4mm x 4mm x 4mm.

I would like any input on if these interdigital corns can commonly lead to ulcers and whether or not I should have done anything more? I havent come across such a deep interdigital heloma durum like this before - and they usually heal straight away! Patient compliance plays a huge part and is frustrating!

Regards

 

It sounds to me like you did the right thing by advising her on her home care routine of dressings and footwear changes and to return in one week. If she had returned for her needed follow-up you could have assessed her home care and emphasised the need to wear wider shoes until healing. Patient compliance is necessary and can be very frustrating when they disregard your advice and care.

Also she managed to go 5wks before another consult...could it be that it wasn't as painful as she was saying and she didn't change her shoes either! Did she offload the area as advised?
Does she have any medical conditions eg diabetes that may complicate the healing of this ulcer?

Hopefully she is now aware of the importance of footwear changes, home care and following professional advice.

 

4mm depth you say? Hmmm I would be very careful with respect to continuing to debride a lesion so close to the bone, as is often the case with these types of toe lesions.. Osteomyelitis is always a potential risk.
Because she didn't return for five weeks, I would have probably informed her at this time that as she hadn't returned for many weeks against my advice, that the lesion has become significantly worse and now needs the review of a doctor/surgeon, in the case of an osseous promonence etc. I tend to practice defensively in these circumstances to minimise any risk of blame from the patient or any future prospect of litigation should complications ensue. As you know, if left untreated for many weeks these lesions become bad very quickly, and the patient often strolls in expecting an overnight cure. Hopefully she will not argue that your debridement under LA is in any way linked to the ulceration, please make sure you fully document everything that has happened.

 

Thank you both for commenting to my original post. An update.... I voiced my concerns as to noncompliance and that I couldn't help her further if she wasn't going to help herself. I sent her on for a surgical review in which she had correction to positioning of her 5th phalanx and debridement, with responsive healing to the ulcer. Osteomyelitis was always at the forefront of my mind. I continue to see her for routine treatment and she is happy with her results yet continues to wear incorrect fitting footwear.

Thanks again.

PS. It never ceases to amaze me those individuals that don't return for review as requested and then waltz in weeks/months down the track when things go pear shaped wanting that overnight cure.