Nasty lesion

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I would like some second opinions on this lesion on the inside of the second toe of an 84 year old lady. She is not diabetic but when she first came to me about a year ago she had a very nasty infected corn on the fourth toe which took many months to heal. I have asked her to go and see her GP but he was not very helpful. It looks very strange to me.

 

Hi zsuzsanna,

Diabetes or not, that looks like ulceration with infection (sausage toe = possible osteomyelitis). If previous lesions were slow to heal, that would indicate PAD (as do the thickened nails).

I`d refer for swab and appropriate AB`s.

Cheers,
Bel

 

Hi zsuzsanna,
I agree will Blinda, to paraphrase, eeek!
Also, the photos are a little blurry, but it seems to me that the wound may be quite deep - is the yellowish-white area in the wound slough or tendon/joint?
If you are in private practice, this may be a difficult case to provide an appropriate level of care for - perhaps there is a high-risk clinic in your local area (usually attached to a hospital) that you can refer to, particularly if her GP is being unhelpful?
Just some thoughts
Cara

 

Greetings.

I agree its a nasty bit. I do suggest that swabs are inadequate for determining colonization of these chronic wounds and we routinely tissue culture them... that is send a bit of tissue from inside the wound. I'm always amazed at what grows from these tid-bits..... but it gives you much greater information.

I doubt that the generalist will be of much help here other than renal status and underlying disease. Its really up to you (us) the foot folks.

I also agree that PAD may be underlying without any systemic general overlay. IF PAD is ruled out I'd also go for a tissue biopsy since chronic wounds do have possibility for malignant change.

Keep us informed! .. Nice catch

 

You need to do a full assessment

As previously mentioned can you refer to public/high risk clinic? Maybe easier


Of you cant call the GP let him know you are concerned and are suspecting osteomyelitis. If the GP is still of no assistance put this in writing and instruct the patient to seek a second opinion. You need to at the bare minimum:

vascular assessment preferably with doppler- refer for vascular consult if PAD suspected

would definately x-ray at the bare minimum. How deep does it probe? possibly OM due to "sausage toe apperance". Antibiotic coverage needed.

Arrange dressings do you have a nursing service that will visit this person for regular dressings and check up. Does this person have the insight to provide any of their own care?

Are they are smoker, whats diabetes control like, other medications etc etc?

Offload-Is the shoe rubbing, is the toe next door causing the lesion? boney prominence etc?

Monitor for improvement if thre is no improvement consider other possible causes as another poster mentioned malignancy (which is rare but can happen in chronic wounds)

hope this helps

 

May I suggest that you refer back to the GP for urgent care?

As Bel has suggested, swabs and ABs are what are needed on an immediate basis.
I can understand that you don't want your patient shunted into a dead-end because the GP won't do anything, but just to continue treating yourself is asking for trouble.

You need to document this with a better pic, with date and time if possible, and send your GP a copy with your referral letter. Stress the word urgent in your letter.

Pods86, the lady hasn't actually been diagnosed with diabetes so probing the lesion is probably not the way forward.
It's up to the GP to ask for x-rays, referral to vascular clinic, monitor for malignancy etc.
At 84 I would be very suprised if the lady squeezes anything more than ABs out of the NHS (other than her other current healthcare needs). But of course that depends on her post-code and the GP.

 

Agreed. I'd say OM is almost certain, and the lady needs multidisciplinery care toot suite.

 

I don't see too much to be overly concerned with.
The infection appears localized to the toe. Although blurry, the wound itself looks like mature granulation tissue. The remainder of the photo; skin looks good, nails are what they are. She is 84.

I would xray to R/O osteo. Debride down to healthy tissue, C&S if you'd like to but I would start with simple bid soaks and local antibiotic cream.
The most important thing here is to remove any pressure from the ulcer.

Good luck

Steve

 

Hi Steve,

It's a bit different over here - you are of course absolutely right in what you say. Unfortunately we have to deal with our NHS service - the transfer of patients from private practice to NHS is mostly less than seamless.

The UK foot patient is treated in PP with no or few diagnostic facilities, or goes into the NHS via the GP. In this case he/she may have a view that at 80+ this patient has "run her race".

I worked with a GP practice not that many years ago which collectively considered that once a patient had reached their "three score years and ten" they were living on borrowed time. It is also not that unusual, in the UK , to write DNR (do not resuscitate) on a patient's notes once they reach a "certain age".
My father-in-law had such a label when he was rushed in to hospital- my wife and her brother disagreed. As it turned out a totally wrong diagnosis had been made and he lived a very full life for another seven years. He died, after a very short illness, aged eighty-two.

 

... hope the lady has gone back to her GP, or even to another GP at her surgery. Agree totally with all other comments given, it does sound like chronic OM - and such a shame the GP did not, but should have noted it earlier on.

 

".....once a patient had reached their "three score years and ten" they were living on borrowed time. It is also not that unusual, in the UK , to write DNR (do not resuscitate) on a patient's notes once they reach a "certain age".

Well, we have Obama care coming our way so we'll be in the same boat as far as choosing who gets what treatment and when.

Steve