Members do not see these Ads. Sign Up.

Hello
I have a 65 year old female NIDDM patient, a smoker, with mild peripheral neuropathy, who had a TNA with matrix phenolisation on a troublesome OG and involuted 2nd nail, 14 weeks ago. The toe is slightly mallet at DIPJ and hence some apical WB but not entirely fixed. The area has not been post operatively infected, she has been saline cleansing and dry dressing daily, and has worn a sandal throughout as she says she cannot tolerate any pressure on the area. The removed nail was very deeply involuted and thickened, and the TNA site wound was deep. It has healed very slowly but it has healed and now has just a pin prick opening remaining.
However she complains of very significant pain both WB and non WB, and again cannot tolerate footwear.
Her blood sugar levels are fine, pulses all palpable .
I am at a loss as to her pain level. My thoughts are : significant OA at the joint, previously masked by the nail pain, other underlying bone pathology, a localised ischaemia ( but visually looks fine), an exaggerated neurological / neuropathic response (could this be triggered by the trauma of the nail removal), a psychological pain response????
I plan to ask the GP for XRays and blood tests.
Has anybody else any thoughts on this????
Thanks

 

I often see this exaggerated pain in smokers secondary to vasospasm of the digital arteries. Advise patient to quit smoking as this is contributing to her discomfort. How long is the digit? Is the D IP joint flexibly contracted? If on weight-bearing this flexion contracture appears to be significant consider flexor tenotomy. As far as local wound care goes consider washing with antibacterial soap and water and adding Bactroban ointment adding a more moist environment for the nailbed to heal. Consider adding an oral antibiotic as this sometimes helps expedite the healing process and reduces the normal flora. Best of luck to you.

 

Even at this late stage it is possible that there is exudate trapped beneath the apparently healed eponychium. Try gently elevating the eponychium (under LA), hypertonic saline footbaths for a further 5 days only and, as mayres has suggested, oral antibiosis for 7 days thereafter.

Let us know the result.

Bill Liggins

 

Keep in mind the possibility of osteomyelitis. An XR would be a good idea. Sometimes the inflamatory response can be suppressed with diabetes, so OM could present more subtly than you think. Another possibility is a small amount of oedema may be making her uncomfortable. You could try using mild compression with a dressing known as Coban, but be careful not to put it on too tight.

 

Agreed; and the OP has already stated that they are going down the route of X-ray & bloods.

Bill Liggins

 

Hello

Thank you to all those who have replied with helpful suggestions.
I saw my patient today, and her situation has not altered. I have asked the GP to arrange for Xray, blood tests, and have asked for oral antibiotics as a precaution. The site remains looking healed and infection free.

However I did lift the eponychium as suggested, and this did prove that there was not a pocket of exudate left, it is all healed and quite normal.

I will see what comes of the investigations, but I am more and more leaning towards more OA at the DIPJ than we suspected, combined with an exaggerated pain response. Upon more personal questioning today, she revealed that she is up to smoking 20 cigarettes a day and is drinking 3-4 units of alcohol per night. She cares for her friend on a part time basis who has MS. My patient is a retired dental hygienist.

Depending upon the results, I have tentatively arranged for a podiatric surgeon colleague to give his opinion.
I will keep you informed of my progress.
Thanks again.