Non healing ulcer great toe

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hi,
i am having 50 yrs old male with 5 yrs duration of
diabetic under control now, has non healing ulcer of great toe
for 1 yr duration.

he has diffuse swelling over the foot up to the ankle recently.
not warm,or tender. probing enters in to interphalageal joint of the great toe.
x ray seems to be normal

I advised to take MRI.

how shall I proceed.?

if bony. or soft tissue involvement is present - treatment?
if not?

suresh

 

First I would ask does the patient have a good vascularity ! I think that a doppler would be better!

 

Suresh

You shouldn't really need an MR for this type of lesion.

One thing to exclude is an accessory ossicle under the IP joint of the hallux. A lateral plain XR with soft tissue contrast should assist to exclude this. Otherwise, in the presence of neuropathy (and exclusion of significant PAD), assume it to be a simple mechanical lesion.

Debridement, offloading and simple wound care should heal this over a number of weeks. It appears from your description that it is not clinically infected, despite being open to bone/joint.

If it is not neuropathic or ischaemic, it is sometimes worthwhile to biopsy it if it has any suspicious features of cutaneous neoplasm.

Reserve MR for a failure of conservative care or high suspicion of acute osteomyelitis.

LL

 

clinically, both dorsalis paedis and posterior tibial is
palpated well

Doppler shows the adequate flow.

x ray...no bony changes.

 

If vascular status is OK, and there is no drainage, no ascending cellulitis, then you probably need to alleviate pressure (friction, shear forces) at the site. We use a modified Darco shoe, with a thick plastizote footbed. The physical therapist makes the footbed, removing excessive pressure from the site of the ulcer. You should see healing very soon. -John

 

I'd use a TCC to get the wound healed then footwear and orthoses to keep it healed. Does he have a Hallux Ridgidus? If so, once the wound is healed it may be worth considering correction.

 

Plantar hallux ulcers are most commonly caused by hallux limitus. We treat these with a Keller arthroplasty through a dorsal incision which increases the range of motion of the 1st MTPJ. The ulcers often heal before the sutures are removed.

Since you can probe into the IPJ, you can assume there is either septic arthritis or osteomyelitis of the joint. This can be treated medically - with 6-8 weeks of oral antibiotics in combination with a Keller arthroplasty to offload the wound, or surgically with joint resection arthrodesis, or hallux amputation.

 

With a chronic wound there are a few things that need to be addresses.

1. Suspect osteomylitis if you can probe to bone. Xrays will not show any changes for about 4-6 weeks. Research has shown that if bone can be probed there is about 80-90% chance of osteomylitis.

2. If the macro-vascular supply is adequate suspect micro-vascular involvement in the chronic wound.

3. Initial cover with broad-spectrum antibiotics is advised. A swab should also be done to rule out any nasties (ask your patient's GP). Even though you've indicated there are no signs of erythema, if the wound enviroment (colour, smell, exudate) has changed, antibiotic cover is highly advised.

4. Deflection is a must. Try either the Darco rocker bottom boot, total contact cast, or Cam-walker with insole deflection.

5. One of the best dressings on a suspected infected wound is silver impregnated dressings. Flushing should only be with sodium chloride.

5. Addressing biomechanical influences also needs to be addressed.

6. If you still have concerns, contact your local hospital's high risk foot / wound clinic for advise.

Hope this helps.

 

With respect to what leecrogers wrote, and also seeing this condition most frequently in conjunction with hallux rigidus, here are effective pedorthic steps of care:

1. Full length custom accommodative orthotic, using multi-density materials and a shear resistant cover.

2. Apply a small crest pad just proximal from the wound site.

3. Make a negative pressure relief from the plantar portion of the orthotic. The cavity may be filled with soft, porous material, as desired.

3. Rocker bottomed shoe with the forefoot flexion reduced to mimic the existing range of hallux dorsiflexion. This can be achieved with a slim graphite shim heat molded to match the internal shape of the shoe and applied beneath the orthotic. Alternatively, the midsole can be temporarily removed so that Extra Firm Molding material (or similar) can reinforce the shoe's existing insole. The midsole/outsole can then be reapplied.