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A lady , who is in her 50s, had an incision drainage of right toe abscess done by orthopaedic on Nov 07'. Her past medical history includes: diabetes and hypertension. Last HbA1c status: 11.1% (Nov 07) ; ESR: 84 (normal: 8-15).

She has been seeing me since Jan 08 for followup. With the change of footwear and dressings issued, 3/4 of the wound across the medial aspect of right 1st MPJ has been healed.
However, the last 1/4 aspect of the wound (located directly on the medial 1st medial mpj) which measures approx. 1cm in diameter seems to be refused to heal!
I would describe the ulcer is wet and red hypergranulating base noted.
No callus or pus/exudate noted. I tried to probe onto the ulcer and moved the hypergraluation tissue abit. Could see a small piece of sharp bone sticking out of the ulcer.
It tends to bleed quite easily after probing onto the ulcer.

*sorry, trying my best to describe what I've seen*

Xrays taken in May and June 08 are as attached. She was prescribed oral antibiotics Co-Amoxiclav 625mg BD x 1 week(Nov 07) ; Ciprofloxacin 500mg x 1week (April 08).

Apparently, she was being advised by the orthopaedic doc to continue dressings daily till the wound heals up. Her current diagnosis by the doc is chronic OM. She's not for any surgical intervention unless the wound worsens.

What's worst, the doc wasn't keen to discuss this case even when I made a request to do so.:boxing:

Let me know what you guys think and any suggestions will be deeply appreciated.
*note: will post the ulcer pic later
Cheerios.

 

Miss Gangrene

There appears to be active osteomyelitis in the 1st MT head .

Bypass the orthopaedic surgeon, request an infectious disease consultant to review the patient, and work with the endocrinologist on organising an admission.

If the last HbA1c was over 11% (!!!) then this patient needs to be managed intensively, and a period of inpatient care would be very appropriate.

If bone is present in the wound, consider it necrotic and basically sequestra. Some aggressive bone debridement in theatre may be required if you can organise this. Work with the ID consultant to determine wether the ostemyelitis can be managed medically, or with further surgical treatment.

Worst case scenario would be a 1st ray amputation by the looks of the films, but MRI may be more appropriate to determine the extent of the osteomyelitis.

LL

 

I agree with LL.
This patient needs debridement of necrotic bone - stat.

Wondering why the poor relationship with the orthopod?
Has he seen this x-ray?
Apparently when he did the original I&D he failed to check the metahead for osteo.

STeve

 

I would be very suspicious of osteomyelits. The radiographs show the eaten out area on the medial head. Also the ESR being high is another clue. I agree with Steve-the bone needs to be debrided.

Regards,

Stanley

 

Hey guys,

thanks for the wonderful replies. This patient will be followed up by a foot and ankle specialist tomorrow. Will keep all posted soon.

Cheerios