Hi All,
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Ive recently been treating a patient with a clawed 2nd toe on the R/F
This patient had a corn on the dorsum of the toe caused by the prominence of the joint
Ive manged to enucleate the corn & used one of those silicone pads cut from a strip
The Strip however has rolled down the toe and trapped under the clawed toe and caused an ulcer.The tendon is exposed and the site is odourous and the foot is noticeably warmer than the left so Im sure its infected
Ive advised the patient to get antibiotics but its proving a challenging task to get the site to heal.
Ive applied betadine,a dry secondary dressing along with TG & Mefix twice but the wound is not improving.I noticed the tendon was just slightly visible on the last visit.
Ive purchased some Amerigel which I will use in conjuntion with the antibiotics my patient receives from his GP.
Any suggestions from similar experiences as to what would be the best thing to do would be appreciated.Thank You
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The first thing to do is to ascertain the nature of the infecting organism, so take a swab. The most likely candidate is Staph.Aureus, but you don't know this until you receive the result, so in the meantime Rx T.Flucloxacillin 500mg qds or T.Erythromycin 500mg qds if the patient is 'allergic' to penicillins (always assuming that there is no contra-indication in either case). The precise dressing, in my view, is largely irrelevant provided that the circulation is patent, but hydrocolloids such as 'second skin' are comfortable. When the ulcer is healed (or before if the defect is large), refer the patient to a Podiatric Surgeon colleague to reduce the clawing of the toe. Again, this is really a matter of addressing the underlying complaint. There may be a number of Podiatric Surgeons in the Manchester area but I do know of Lewis Stuttard who practices in Rochdale and who would, I am sure, be able to help.
All the best
Bill Liggins -
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Also agree with Kevin;
Skin & Soft Tissue Infections - Diabetic Foot Ulcer
Take culture swabs if there is evidence of clinical infection such as increased pain, enlarging ulcer, cellulitis and pyrexia, then initiate empirical treatment. Consider risk factors for MRSA colonisation (recurrent abscesses/contact with military personnel/engages in contact sport). Consider referral for specialist opinion.
When to investigate;
Take culture swabs from cleaned base of ulcer if there is evidence of clinical infection. Alter treatment in response to culture and sensitivity results. Seek microbiological advice if colonised with MRSA.
Treatment choices First Line:
Flucloxacillin 500mg qds
PLUS
Amoxicillin 500mg tds
Review after 14 days
(Add Metronidazole 400mg tds if offensive)
If penicillin allergic or known to be colonised with
MRSA
Doxycycline 200mg stat then 100mg od. Review after 14
days.
(Add Metronidazole 400mg tds if offensive)
Cautions Clinical signs of infection may be masked in a person with diabetes and it important to have a low threshold for considering
antibiotic use, especially in someone with a neuro-ischaemic ulcer
Evidence Available evidence does not support treating clinically uninfected ulcers with antibiotics, but antibiotic therapy is indicated for
almost all infected wounds in conjunction with good wound care
References Clinical Knowledge Summaries Diabetic Foot Ulcers www.cks.library.nhs.uk accessed 31.3.08
Cheers,
Bel -
Just a note of caution re: Kevin's otherwise good advice.
The situation may well be different in the States; however, in the U.K. you should refer to a Podiatric Surgeon colleague rather than to an Orthopaedic Surgeon. The current attacks on this profession from the Orthopaedic profession are such that they should be given no encouragement.
All the best
Bill -
hlh494
With respect, if I am correct in assuming you are seeing this patient privately, I get the feeling that you are out of your comfort zone and should be referring this patient to the NHS for immediate treatment and resolution as they have the back up that may be necessary.
Cornmerchant -
Bill Liggins -
Bill
I was thinking of the more immediate need for healing the ulcer which is better served in the NHS with full access to wound management team and their backup. Agreed long term that the problem needs to be addressed, however remember that it was the choice of protective device that caused the ulcer in the first place. Chances are that the patient does not need surgery- many patients l know live quite happily with clawed toes.
regards CM -
Cheers,
Bel -
All the best
Bill -
Bel
I think there is a difference between the breakdowns that we all see regualarly and the sudden appearence of a tendon! The OP is obviously struggling and out of their depth hence the advice to refer on.
Did I say anywhere that I dont inform the patients of "choices" ?
CM -
Evening CM,
Cheers,
Bel
PS sorry to be a tad whingy today....my week is not going well and it`s only Tuesday:boohoo: -
Use of Betadine on an openwound or ulcer is not recommended. Its use is limited to intact skin antiseptic application.
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I know
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All the best
Bill -
yep, what Bill said.
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