Thrombosis in the foot

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Hi Everyone,

I have an 84y.o female patient with medical history including L/Total hip replacement, Chronic back pain, osteoporosis, IBS and Asthma.

She presented to clinic with acute focal pain, erythema and swelling sub right 3rd MPJ, with a small ‘lump’ felt on palpation.

On assessment no obvious biomechanical abnormalities, however her footwear was less than desirable, due to narrow nature and shallow depth, making any offloading attempt difficult at best and with her unwillingness to change her footwear making it harder to treat.

DDX included acute bursitis, capsulitis, mortons neuroma.

At time of assessment I added a thin layer of slow release (red) poron lining into her shoes which made them more comfortable to walk in according to the patient.

I sent her off to have a Diagnostic Ultrasound and was a little shocked when the report came back with there being a 6mm long focal thrombosis in the vein within the subcutaneous fat layer overlying the plantar surface of the 3rd MPJ corresponding with the area of focal tenderness.

Is this common?
Have many people seen it before?
How is something like this usually managed?

Thanks,

Nick

 

Hi Nick

Just yesterday I had a very similar pt. Presented with focal pain and marked dorsal and plantar swelling over-lying the 2nd MPJ of her right foot. No obvious trauma and unremarkable biomechanical features to suggest this acute onset.

Also DDx: capsulitis, neuroma, stress #, subluxation......

The radiologist called me to say there was too much oedema to make any diagnosis but did say there was 2nd metatarsal oedema as well. An MRI was peformed which found numerous effusions and bursitis as well as a 4mm thrombosis in the intermetatarsal artery.

Of interest, was the resultant swelling of the 2nd digit with no obvious ischemia or pain on palpation or movement.

I have referred her for a vascular consult as I too am not sure of the appropriate treatment.

In my 15 years of practice, I have not come across this before.

Good luck with your case

Regards

Brandon

 

Welcome to Podiatry Arena Nick. Great posting form you and Brandon. Thanks. I have not come across this in 30 + years? Or maybe I have just missed the diagnosis. It will now be on my radar,

Well done.

Cheers

Heather

 

Thanks for getting back to me,

I sent a letter back to the patients GP asking if the use of antiplatelet or thrombolytic agents was indicated and suggested a possible referral to a vascular surgeon for further review/assessment.
If/when I hear back from the GP I will post what they decided to do.

Nick

 

Great case and excellent example of how good clinical skills leads to a good diagnosis. I too have never seen this clinically would be very interested in the outcome Nick. Well done!

 

Hi Nick

Interesting case.

Any chance that you could get hold of the US image(s) or video which lead to this diagnosis and post it with patient's name DOB removed? This would increase value of this case study.

Cheers

Martin

Foot and Ankle Clinic
1365 Grant Ave.
Winnipeg Manitoba R3M 1Z8
phone [204] 837 FOOT (3668)
fax [204] 774 9918
www.winnipegfootclinic.com

 

Hi Martin,

I haven’t had the opportunity to see the US images myself, I’ve only read the report and unfortunately I am about to move back to my home state to start a new job so I don’t think I will have time before I leave my current job to get the specific patient back in to see me again to bring the US images in.

She was seen by one of my colleagues last week who told me that she has yet to have any intervention undertaken for it that I had previously requested to the GP; however it is possible that she is awaiting an appointment with a Vascular Specialist.

Cheers,

Nick

 

OK thanks Nick

Cheers

Martin