Advice for my first ulcer

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Hi all,
Treated a pt today, routine nail cutting, and she reported a corn on side of 5th toe. Looked like a corn on first view but then noticed it was a little yellowy/brown. So gently removed the top layer (a tad soft for a corn) and underneath revealed a very small area (size of a pinhead) of tissue breakdown. Pt reported was painful and bin there a couple of months only (so not corn). So dressed with inadine, melolite and tubegauze etc. Didn't detect any tracking and was not infected (no redness, smell, puss etc) am going to return 48hrs to reassess and redress (told pt to keep dry).
Patient history- age 77, DVT (same leg) 3 years ago, ankles slightly oedematous pt takes furosemide. All pulses (dp and pt) palpable.
Footwear was fine however pt had purchased new slippers that look a little narrow so advised etc.
Will reassess when return if takes a turn for worse then I refer to G.P. with a letter? If shows sign of healing make return appt 3/4 days? and provide some tubefoam or gel tubes to cushion area and prevent happening again.
Does this sound ok? Just want to make sure im doing the right thing.
Thanks.

 

Re: my first ulcer

Hi Clod,
It all sounds fine to me, you seemed to have covered all the bases.
Never be afraid to ask the patient to come back to re-assess. They will appreciate your concern and you can then monitor the situation.

Keep up the good work!

regards

Catfoot

PS Just a tiny point - "Puss" is one of my pals and is often found in boots, "pus" is the result of tissue breakdown....

 

Re: my first ulcer

thanks catfoot
love your no nonsense aproach - have you thought about being a student mentor? compared to some i had - slightest whiff of an ulcer "move over i'll deal with this" i think you'd be fab.
I did say to pt that i wanted to reassess in 48 hrs and she did seem alittle alarmed but i said it was more for my peace of mind cos i not been doing long and just wanted to keep an eye on the situation and make sure its healing ok and i think she was ok with that. So hopefully be ok.
Might be a bit trivial - but its a big deal to me, this is gonna be the biggest learning curve of my life despite the three years training, so just wanna make sure im doing the best by my patients. I would have loved nothing better than to walk into NHS job where you're assigned a mentor for a year but no such luck! Had to bite the bullet and get on with on it! So any advice much appreciated.

 

Re: my first ulcer

Clod

Welcome to the working world.

Time to approach this, as everything, in a pure diagnostic fashion.

You say:

and,

You also say it is on the "side" of the 5th toe.

Firstly, the geriatric foot is prone to soft tissue pressure lesions. Check for underlying clinical and subclinical peripheral neuropathy. Correlate this to any medications that may be contributing to this also. What is her capillary fill time like? Do you have a view on her tissue oxygenation - (eg hx of COPD), has she been on corticosteroids?

Finally, start doing the "podiatry" bit.

Where is the corn? Is is medial or lateral to the PIP or DIP joints? Is there an underlying bony prominence that is palpable (eg osteochondroma, OA)? Why has the corn occurred "there"? Is there an adductovarus deformity in the toe?

Try to understand "why" the corn has ulcerated (remember, it was a corn before it broke down). Think about the underlying bony structures. And finally, try and establish if there is a neuropathic or arterial component to the ulceration.

Like eveything, once you understand what you are dealing with, the 'fixing' bit is easy.

LL

 

Re: my first ulcer

Hi LL

in answer (i try me best, see your point)
I would presume no neuropathy as pt reported it was painful, however as she was not diabetic i did not do the sensory testing but am returning on Sunday so could carry out.
The 'side of the toe' in technical terms over the DIP joint on the lateral side.
Capillary refill was 1 second.
No corticosteroid history, in fact pt pretty healthy, apart from furosemide pt takes omeprazole, paracetomol, pizotifen (migraines) and iron tabs.
Didn't detect any boney deformities apart from slightly swollen ankles feet were pretty ok, no hammer toes, claw toes etc i think maybe just rubbing on new slippers which i advised about, but does make you think why tissue breakdown and not just just a straight forward blister? Personally i think maybe related to preious DVT in knee same leg and maybe compromised blood supply however pulses were palpable....

 

Re: my first ulcer

hmm LL
you got me thinkin now (a good thing)
Theory #1
pt was quite sedentary when i visited but ankles were swollen, perhaps when patient more active feet swell a little too causing a disruption to the normal inflammatory response. Maybe water tablets need adjusting?
Theory #2
History of previous DVT and migraines might indicate the need for blood thinner medication which may explain disrupted blood flow to the peripheries
Just a theory, probably showing my inexperience here, but no point this little ulcer healing only to reoccur inbetween appointments and take a turn for the worse..
hmmmm

 

Re: my first ulcer

Good to see you're thinking Clod,

Now start thinking about what kind of oedema it is. Is is due to venous insufficiency of increased fluid retention (eg right heart failure). Given she is on frusemide, what does this mean?

History of DVT is a very separate issue to migraines (multiple causes). Unless she was on a platelet modifier, this probably presents little relationship.

If you feel her arterial perfusion and neurological status are intact (don't just check this for diabetics, it should be part of any basic foot assessment), then turn back to the lesion itself.

You suggest it is lateral to the DIP joint, which suggests to me it is at or near the lateral nail sulcus (Durlachers' corn). These are usually associated with hypertrophy of the lateral base of the distal phalanx, degenerative joint disease and peripheral osteophytosis, or even an osteochondroma. Palpate under the lesion, or get a plain x-ray to assess further.

Is the lesion associated with weight-bearing pressure, or lateral shoe pressure. Observe the toe in relaxed stance. Typically a corn lateral to the DIP joint is due to flexor dominace, adductovarus deformity and weight-bearing pressure; rather that lateral PIP joint lesions, which are usually due to extensor dominance and lateral shoe pressure.

Once you work this out, turn your attention to the most suitable offloading option (orthodigital appliance vs. shoe modification vs. arthroplasty if recalcitrant).

Hope this helps,

LL

 

Re: my first ulcer

Hello again Clod,
Thanks for your vote of confidence in my abilities as a student mentor, but at my time of life I am a bit old for a career change!

It seems I misunderstood your post, I thought the patient was coming to a clinic. I now see that they are a domiciliary patient. Are they having a dom visit by choice or because of mobility issues?

LL, your answer is very comprehensive and useful, but in UK pods don't have access to X-ray facilities directly unless they are working in a specialist team in the NHS. If we see anything that raises our suspicions about an underlying medical condition, we can only refer on the the GP or if it is a simple re-dressing, to the District Nurse.

Clod, may I suggest that you seek out the Tissue Viability Nurse in your area and check with them what referral pathways are available to you? I suspect that the GP is the gatekeeper here, but it doesn't hurt to make yourself known.

In my experience most small simple tissue breakdowns resolve quite quickly. If they don't then you could be looking at a complex situation that could be better dealt with by the NHS Specialist Podiatry Team. Don't be afraid to refer on if that is the case. Recalcitrant ulcers can be very frustrating to deal with, needing frequent re-dressings and from a cost point of view better for the patient if the NHS take over.

Anyway, let's not get ahead of ourselves here. You may find on your next visit that the lesion has healed and all is fine and dandy. If it hasn't, then it's time for the thinking cap again.

regards

Catfoot

 

Re: my first ulcer

Hi Catfoot
The pt chose dom visit as OA in hips causing slight mobility issues - pt uses walking stick, however she was attending a clinic regularly, she said she was fed up getting taxis etc as it was quite a distance for her to travel.
I have asked my sister about this (she's a district nurse and does wound dressings all day!) and she said to keep an eye on it but if goes worse then to call the G.P out or ask for a district nurse home visit (same as what you said)
I'll check tomorrow, fingers crossed.

 

Re: my first ulcer

Whoa....

Steady on guys.You are going to frighten poor clod away !

clod- over time you are going to see many such breakdowns /ulcers, but as a newbie, you cant help worrying that you are doing the right thing!

From what you say, you have done all the right things. If this was a one off from the slippers it will heal and may never return. If it fails to heal or recurs then you need to start looking for reasons and
providing solutions!

LL provides excellent advice and it is good to get you thinking, but dont make a mountain out of a molehill. Catfoot has it just right , there are referral pathways in the event of ongoing problems, and you must use them if you find yourself battling with something that wont heal. Do not be a martyr!

As time goes on you will gain confidence through experience- dont do what i did as a newbie- a patient rang me regarding an ulcer on her little toe and i was so keen to get to her I got a speeding ticket! I calmed down a little after that!

Good luck, I am sure it will be fine

CM

 

Re: my first ulcer

Hi clod

You sound as though you're doing all the right things so far, and it's good that you have sought advice from colleagues and your (RGN) sister.

You say your lady has hip OA ... exactly how mobile is she? Assuming she's OK putting on shoes, could you gently (!) persuade her to wear a pair of light shoes (that fit) with adjustable fastening, indoors? IMHO slippers cause all sorts of probs.

 

Re: my first ulcer

hi lusnanlaogh
Yes i am inclined to think its a 'shoe/slipper' cause but am back for revisit tomorrow to assess. So will address the footwear issue again. The new slippers did look awfully narrow and i did say they may have contributed to sore toe and something wider would be more suitable. (I have a heap of catalogues that i carry round from cosytoes to hotters but she didnt seem interested)
She appeared to be quite mobile, lives indepentantly just seems a bit 'stiff' with OA (hip) and uses stick to aid walking. She did mention that she gets about to shop, hairdressers etc ...
Will report tomorrow on progress of toe......fingers crossed.....

 

Re: my first ulcer

I know it can be difficult to persuade some of the oldies to part with their day time slippers, but it can be done.

You just need to gently plug away at it ... be consistent, be persistent, explain what might happen if they don't change and leave them a catalogue (don't forget to mention the companies you mentioned are very good with returns). It can be like wading through mud sometimes (don't take it personally) but it can be done. Whatever you do, make your point but don't nag.

Btw depending on her foot shape, Cosyfeet may be better than Hotter ... ?

 

Re: my first ulcer

Hi all,
Just returned to change dressing and looked a lot better, the base of the lesion not as red and appeared to be starting the healing process, most importantly the pt reported it felt alot better.
Addressed the shoe issue again and the pt showed me her 'shoe' cupboard - good grief this lady likes to shop!! I think this may be why she wasn't interested in purchasing any more! The shoes she showed me at first appointment were her 'good shoes' and then she pulled out another pair and said 'when i wear these they really hurt my little toe'........so gently advised not to wear them in case the lesion returns, she agreed.
Redressed again with inadine etc and will return on weds, if still improving should i put a dry dressing and SOS if any probs? She has rebooked in 7 weeks for nail cutting.
Thanks everyone for all your help.

 

Re: my first ulcer

Hi clod, not too sure if this has already been mentioned, but pressure offloading? Common site on the 5th if footwear has been rubbing. Tubegauze can just bulk up the toe box and increase pressure. Work to actively remove pressure fom the lesion, semi compressed felt and maybe cut hole in new slippers if the cause? Only thing i would add, everything else sounds fine and seeing her back is a good isea!

If wound hasn't healed continue to see her until you are happy with it and she can do her own dressings at home/district nurse to continue dressing it?

Had a patient like this myself recently, new footwear had caused blister on r/3rd PIPJ and l/med calc, very poor vasc, and poor skin integrety, hx of amputation b/2nd due to same ulcerative properties from rubbing footwear, blister broke down and ulcerated. Used an alginate dressing we have here, flaminol hydro gel (great stuff) and dressed, pressure offload and anti-bs as there was active infection and cellulitis tracking up the foot. Still not happy with it and as skin intergrety poor trying to minimalise the adherant dressings! seeing her again tomorrow and if better will ref to district nurse for dressings and review 2weekly.

Also sorted shoe problem, she has new shoes made already with a neoprene upper, excellent replacement for softer leathers as moulds around mis-shapen toes!

Just an example of how i have handled one of my wounds, good luck with it!!

 

Re: my first ulcer

Hi Clod, I see your in the Manchester area. Whilst I'm not declaring I'm the font of all knowledge i'm sure I can offer a bit of professional support if you need it. Just drop me an email. Do you attend branch meetings? (With the arrogant assumption your a member of the Society). I'm vice chairman of the Lancashire Branch, so if you fancy popping along to a Lancashire Branch meeting or I'm sure the manchester Branch will be just as accommodative.

I've sent you a PM with my email.

George

 

I always take a DB shoes catalogue with me so I am able to point out the the type of wide and deep enough house shoe or slipper that would optimally accomodate. The full catalogue has a template that the pt stands on which a helper/family member draws around while the pt is standing on it. Many of the slippers have a velcro flap fastening which allows the pt to release/adjust if one or both feet become swollen. I make it clear to pts that I am not on commision from the company, just have their best interests at heart.
find them on www.widerfittingshoes or just search DB shoes.

 

Hi Clod

Sounds like your doing an excellent job and as has been said before your going to come across loads of such ulcers and almost always they will resolve with the type of treatment you are giving. If the ulcerated or infected corn is at the joint or apice of the toe and the toe is ridiculously tender to touch or the lesion has a sinus then I often ref for an x ray query avascular necrosis / osteomyelitis.

Here's a couple of papers that might help for future reference.

Cheers Dave Smith

 

dont think 2 hard if it has not healed in a week refer to gp/district nurse as catfoot says its not practical to do 2 dressings per week for next 3 months if the patient is having to pay. you wont lose the lady as apatient but sometimes its best to pass pts on to a more appropriate pathway. if its recalcitrant she will need antibiotics nhs dressings etc, x ray micro biology swab etc etc

 

Hi Fishpod,
I returned to pt today to check on things and lesion looks almost resolved (redness gone), area of tissue breakdown healed, just a small (1mm across) area of epithelialisation on the surface. I pressed the area (quite hard) and she said pain completely gone.
Reiterated about shoes again pt seemed very compliant. Left her with some tubefoams which she said she will use when out walking etc. Have told her any probs, i.e. starts to feel sore again to contact me straightaway. Am back in 6 weeks for nails so if lesion returns will definately refer on.
(PHEW)!
Thanks everyone for the info, appreciated.

 

Hi Clod

The whole ulcer care plan and treatment pathway seems to have been dealt with by all of the excellent posts above but what I wanted to say was that I feel for you. Whilst it is always good to document things on here for the rest of us to see I feel sorry that it seems you can not get this advice from management and colleagues at work.

Is it just me or is it worrying that a new grad (i assume this as your first ulcer, forgive me if not) can not or is not getting the support you need from those around you.
As one post said above, welcome to the working world. Keep up the good work and good luck.

Kal

 

kal / clod gets no help i suspect hes in private practice and it can be quite isolated. regards fishpod

 

Hi Kal/Fishpod
Yes, very much a one (wo)man band! - (secretary, marketing agent, accountant, postman, cleaner etc.. and podiatrist)
Am still in touch with some other grads tho who are in same boat and I'm looking into attending local SCAP branch meeting.
Have also had offers of professional support/advice (via email) from other pp's thanks to pod arena.

 

Fishpod, good detective work, I had not thought of that.

Clod, I feel for you even more now. As a new grad and working alone I can imagine it may be slightly daunting. Keep up the hard work and I am sure the experience will be worth it.

 

Welcome to the transition from being a student, where there is someone else to tell you whether or not you are doing the right thing, to the real world where your degree tells the public that you kown what the right thing to do is. Be able to defend your descision and know why you do what you do.

I'd recommend the James Herriot books for a nice retrospective on the process of gaining confidence in clinical practice.

Eric