Ingrown nail, bone spurs, RSD opinions?

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This patient is a 54 year old thin female who had a pedicure in January 2011. The right great toe medial distal nail border was cut on an angle. She immediately had pain that she still has to this day. She had the toenail removed on the medial aspect straight back twice without matrixectomy, but had no pain relief. After a third surgery with surgical matrix removal on the medial side in March the patient had more pain that has remained at that intensity. The pain has always been halfway up the medial toenail border. There is now also pain at the medial proximal toenail area and intermittent pain along the lateral toenail border.

The patient has started to have sympathetically mediated pain on the bottoms of both feet with pain with light touch, hyperpathia, temperature changes, mottling and pain with standing on the soles of both feet, consistent with RSD. The pain is starting to move proximally to her leg and arm on the affected side. She can not wear closed shoes without pain.

The patient has had lumbar sympathetic blocks and been getting ketamine infusions with no relief. A neuroma as a source for the pain was ruled out by the MRI. The only pain medicine that has given relief is oxycodone. Her pain stays at a very intense level all of the time. She is on a high dose of Neurontin without relief. She has been unable to tolerate anti-depressants for pain relief.

I have attached x-rays, recent photos of her toe and an MRI image from June. The nail is growing at an angle toward the distal phalanx. I believe the nail is growing closer to the bone since it was narrowed and it is exerting more pressure against the bone. She has a spur on the medial proximal base of the distal phalanx (visible on a magnified view of the oblique x-ray image). She also has an enlarged medial distal tuft of the distal phalanx. I believe the tuft is enlarged and it is approximating the distal medial nail border. In some people, this bone would not be a problem. With a deep ingrown toenail growing toward the bone where the nail has been narrowed, the bone could be too large for her. The lateral toenail border is ingrown, but it is growing away from the bone. She has typical pain there consistent with an ingrown toenail.

I encouraged her to get multiple opinions. Permanent removal of the medial border of the nail has been suggested. I do not believe this is a good option, since this would allow the distal and proximal medial aspects of the phalanx to get pressure from her shoes. The bone would get larger and present a greater problem as she gets older and her skin gets thinner. Pressure appears to be a trigger for her RSD, since she had increased pain following a PT nerve block.
A nerve ablation has been suggested. I do not believe this is a good option, since this can cause trauma to the surrounding tissue and could spread the RSD.

My suggestion is to remodel the distal medial and lateral tuft of the distal phalanx and remove the spur on the proximal medial base of the distal phalanx. This will decrease the pressure under the nail. If the RSD is being triggered by the pressure on the tissue between the nail and the bone, I am hoping this will alleviate the sympathetic outflow. At a later time, the medial and later borders of the nail can be permanently removed to avoid continuing nail trimming with an instrument in this area. The nail would be left wider than the bone, so that the nail would take the pressure from the shoes, rather than the bone.

I would like to get some opinions on what you would recommend for this patient. What do you believe is the source of her pain? Any procedure can exacerbate the RSD, even regular trimming of the nail border to keep it short of the distal tuft. She would have to have this done under a nerve block, which could increase her pain due to vasodilation. Constant nail trimming could present a problem by aggravating the RSD. Any surgical procedure would be done using ketamine for anesthesia. The patient does not want the ablation procedure. She agrees with me that the bone is the problem.
Thank you for your participation in helping this very nice lady who is in a great deal of pain.

 

Boy, is this a tough one. You may be right, removing the exostoses may help. But they don't look very large, and the nail isn't humped in the usual way for a regular subungual exostosis.

You probably can't get control of the RSD (CRPS) without removing the original source of pain, but you want to tread carefully. It may get worse after you do the surgery, and even if the original problem is fixed, the RSD may be forever.

How long has it been? Physio and drugs are the basic options. Lyrica may help since gabapentin hasn't.

Just remember that constant unremitting pain makes people crazy and angry, and if you are the last one to touch her, you may carry all the responsiblity.

Cheers

Frederick