Complications of an ingrown toenail

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A lovely 70 year old female presented with a toe infection on-going for a few days. She relates having an ingrown nail causing her pain and was subsequently removed by a podiatrist. 

She is a diabetic and admits to going back to work after the procedure. Several days later I was called to see her in the emergency room. See far left image. There was increasing redness, swelling and purulent material draining out the nail bed. Her prognosis was bleak. 

I didn't know if the toe could be saved but I told her I would try. I worried that if we did nothing, the infection would spread affecting other parts of her feet. So we wheeled her into surgery right away. 

Paying close attention to the blood source to the toe, an incision was made down the middle and the infection was gently cleared out with a curette. The wound remained open to allow further drainage. She was admitted to the hospital for IV antibiotics and debridement was performed daily until I was comfortable that the infection was controlled. 

Several weeks later, she is doing quite well. 

Complications of an ingrown nail is rare but the risk is still present, especially in patients with diabetes. It is important for patients to feel comfortable in addressing any problems they have after a procedure immediately with their doctor and equally important for the doctor or their medical assistant to be available as well. Don't take any procedures lightly and as you can see here, complications are real but if dealt with in a timely fashion, prognosis can be good. 

 

"I think I have an ankle fracture. Now what?"

XR of an ankle (fibular) fracture

XR of an ankle (fibular) fracture

Breaking any bone in your body is frightening. Not only does it hurt but fear of surgery and long term disability is on everyone's mind. My husband recently missed a step going down stairs, he was holding the dog's leash in one hand (and she was pulling) and his cell phone in the other (I don't see how this was a good idea to start with). His foot turned under him and ... SNAP! He heard and felt a pop, called me immediately and fortunately for him had concierge service from his favorite podiatrist. He told me "I think I fractured my ankle."

Luckily my office wasn't too far from where he was so I was able to drive him to the office and get xrays immediately, bypassing the emergency room. Of course, the whole time he was very scared that he would need surgery. He himself is a general surgeon and runs around all day and night going between patients traveling to different facilities and stands for long periods to operate nearly everyday. His job, like many others, requires him to ambulate independently without pain. So, what was next for him?

His xrays were negative for an ankle fracture. But what was that audible pop and the immediate bruising and swelling? He may have torn one of the lateral ankle ligaments but since he was not a professional athlete, I advised him to take the following protocol seriously so he can heal optimally without surgery, the acronym R.I.C.E. protocol is appropriate here:

1. REST - I realize many working people don't know how to do that. He was given a walking boot to protect the ankle and was instructed to wear it during working hours, then take it off when sleeping or driving. Functional recovery (continued protected movement) is important in ankle sprains. In the evening, he was to do passive range of motion exercises, drawing out the alphabet with his foot. Too much immobilization could stiffen the ankle and weaken the leg slowing down recovery. 
2. ICE - this will decrease the swelling
3. COMPRESSION - I applied an elastic ACE wrap to help with the swelling
4. ELEVATE - raising the affect leg above the heart while at rest will also decrease swelling

(or P.O.L.I.C.E. - Protect, Optimum Loading, ICE, Compression, Elevation)

He only took a few ibuprofens in the beginning but went straight back to work the following day taking it slow. Of course I'd occasionally find his boot laying around the house every now and then while he was at work, so you can say he was doing fine. After 6 weeks he felt pretty normal and went back to working out and running comfortably.

By the way, if it was an ankle fracture, that doesn't necessarily always mean surgery. Allow your surgeon to make the diagnosis and discuss treatment plans with you. The sooner you seek treatment, the better off you'll be. 

 

 

Elderly Foot Care

The age at which a person is considered "elderly" may vary from culture to culture but it has been accepted (in the US) to be those of age older than 65. October 1 is International Day For Older Persons so I wanted to share some insight about elderly foot care from a podiatrist's perspective.

A large portion of my practice focuses around the elderly and here are some important issues to consider.

1. Gait imbalance - There are many reasons for gait imbalance and some can be easily addressed with orthotics, braces, walking assistance aid (walker, cane). Other times, physical therapy is needed to improve joint mobility and conditioning to prevent falls. Podiatrists can determine whether or not your feet is the cause of your imbalance and make recommendations.

 What I would highly recommend for prevention of falls at home (that I learned in my gerontology class from medical school) is GET RID OF LOOSE RUGS around the house and loose cable wiring also. These can lead to tripping and falling, which can have disastrous results in our geriatric population.  

2. General foot care - Common problems seen in elderly feet:
- Dry feet that may crack and is too hard for patients to reach to apply lotion
- Painful corns and calluses
- Thick and discolored toenails that are difficult to trim
- Circulation issues including cold feet, pain at rest that feels better when the legs are dangling, or intermittent claudication (pain with walking short distances)
- Osteoarthritis and joint stiffness
- Hammertoes and bunions are progressive deformities that worsen with time and can be very painful

Many of these issues can be treated by a podiatrist with simple procedures performed in the office the same day as your appointment.

3. Undiagnosed depression - Often times, patients seek medical help but they often hide their depression, either from chronic medical conditions or loneliness. Since podiatrists see a lot of elderly patients, we work closely with your primary care doctors to discuss social issues that affect this vulnerable population.

For more information on Geriatric Care, please visit https://geriatricscareonline.org/

Photo by Rawpixel Ltd/iStock / Getty Images

Photo by Rawpixel Ltd/iStock / Getty Images