Red 5th Metatarsal

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Hi folks,
saw this pt today but have now had glass of wine so apologies if not completely clear!!!

pt aged 60 has had gout (none for the last year) and currently sciatica down R leg (pain down to 1st toe for last 8 weeks)
Pt has swollen, painful intermediate phalange of R 5th digit - pt almost jumped when palpating. Looks possibly infectious (swollen, hot, red etc), but no obvious wound or any history of any trauma.

What I'm wondering if it could be trauma from changing gait due to avoidance of 1st - although when looking at gait, nothing obvious(!) or if it's possible to get an infection of the intermediate phalange without anything obvious?! Or is it possible to break a phalange without the pt knowing?!

Thanks guys!

Lucy

 

Lucy,
Considering the previous history of gout, I would suspect a gout 'attack' affecting the 5th toe in the absence of trauma or obvious portal for infection.

Also, the intermediate phalanx of the 5th toe is really quite small so are you sure this is the probematic structure? Is the erythema and pain specifically at the level of the intermediate phalanx or is the whole toe affected? I would rarely be so confident to pin point the exact site of maximum discomfort in the 5th toe (especially if the toe is so sore that you cannot really examine it it) unless there was an obvious visible lesion.

Of course you can get haematogenous spread of infection but I'd be inclinced to think of the obvious first unless there is something else in the patient history that would point you in another direction. If it looks like a pig and sounds like a pig, it probably is a pig.

It's quite difficult to give a more useful opinion without a picture.

Ryan

 

I'm with Ryan.

Can you post a pic?

 

any history of psoriasis? Don't forget DDx Psoriatic arthritis?