04/30/2013
QUERIES - (CLINICAL)
Query: Chronic Onychomedsis
Is there an effective surgical procedure or other treatment that can cause a toenail to "tack back down" to the nail bed where the distal margin is elevated, but the proximal margin is normal and growing?
Joseph Reynolds, DPM, Visalia, CA
10/23/2012
QUERIES - (CLINICAL)
Query: Debridement of Heloma Molle
Does anyone have any pearls to share regarding debridement of heloma molle? I find it very time-consuming to debride these interdigital lesions.
Catherine Wu, DPM, Revere, MA
06/16/2012
QUERIES - (CLINICAL)
Query: Chronic Calcaneal Apophysitis
My patient is a 12 year old boy with severe pain to his right heel. He cannot bear any weight on it. There is no history of trauma. X-rays are consistent for apophysitis. An MRI was consistent for apophysitis and not suggestive for fracture or osteonecrosis. There was a small amount of fluid noted to the retrocalcaneal bursa consistent with bursitis. Because the child was not able to bear any weight, I dispensed crutches.
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Chronic Calcaneal Apophysitis |
The father took the patient to a pediatric orthopedist who placed the child in a BK cast for a couple of weeks. The child came back to me still with severe pain, and now with less dorsiflexory motion at the ankle on the affected side. His pain has been present for 3 months now. Is there some other differential diagnosis or treatment option I should consider?
Jeffrey Kass, DPM, Forest Hills, NY
04/10/2012
QUERIES - (CLINICAL)
Query: Metatarsus Adductus in 14 Month Old
I have a 14 month old patient who has a moderate to severe metatarsus adductus who started walking about 1–2 months ago. The mother had been told that the child would most likely have the problem resolve on its own. It has not. 1) At this age, is casting still appropriate because she is walking? 2) It has been a long time since I did this form of casting. Could someone advise me on the correct technique? 3) Would a Wheaton Brace be appropriate for this age, especially with the patient walking? 4) Because the patient is walking, what alternative treatments would be best for this patient?
Edmond F. Mertzenich, DPM, Rockford, IL
04/20/2011
QUERIES - (CLINICAL)
Query: Post-op Nail Complication
I have a patient who is three months post-NaOH matixectomy who still has not healed. There is no pain or cellulitis; the site looks like a normal post-op nail. Cultures were done originally and grew out Staph epi/sensitive only to Zyvox or Vanco and Pseudomonus of which I treated her with Cipro/Zyvox for two weeks. MRI was negative for osteo and biopsy of the nail bed was negative for pathology. This week, I told her to use Betadine ointment daily and gave her an Rx for Diflucan for one week to cover any fungal causes. The patient is healthy, non-diabetic, with excellent pulses. Any suggestions for causes and future treatment options.
Brent Rubin, DPM, Bradenton, FL
04/19/2011
QUERIES - (CLINICAL)
Query: Exogen Bone Healing System
Does anyone have any experience with Smith & Nephew's Exogen Bone Healing System? I have recently been detailed and am thinking about using it with all osteotomies, even routine low-risk ones. They claim to decrease healing time by up to 40%. Does this mean that I can ambulate patients up to 40% sooner on osteotomies that I would usually keep non-weight-bearing for 4-6 weeks?
Tip Sullivan, DPM, Jackson, MS
04/18/2011
QUERIES - (CLINICAL)
Query: Allergic Reaction to CaSO4 Beads
Given all of the obvious variables, has anyone ever seen a suspected allergic reaction to the sulfur component of the Wright Medical calcium sulphate antibiotic-impregnated beads? Should you use them in patients who are allergic to p/o sulphates?
Tip Sullivan, DPM, Jackson, MS
01/29/2010
QUERIES - (CLINICAL)
Query: Botox for Jones Fractures?
A patient presented with a classic "Jones" fracture of the 5th metatarsal. While explaining this injury and the often delayed healing that goes along to the patient, I was asked myself, why does this fracture (besides the circulation issues) take so long to heal? I wondered if the pull of the peroneal brevis has a role. What would happen if Botox was used to paralyze this muscle during the healing phase? Normally, I would either operate, cast-immobilize or both, so that paralyzing the PB would not have any effect, other than removing the tonic contraction that may disturb the healing process. Comments?
Bret Ribotsky, DPM, Boca Raton, FL
01/27/2010
QUERIES - (CLINICAL)
Query: Palpable Mass in Dancer
I have an extremely active 15 yo female dancer with a firm palpable mass just above the insertion of the Achilles tendon. She dances competitively in all types of dancing and practices at least 5 times a week. The lesion is palpable on both direct and lateral pressure and does not exhibit any of the typical characteristics of verrucae. Since she does not want to stop dancing for any period of time, my treatments seem very limited.
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Palpable Lesion in Dancer |
After ordering an MRI, my optimum approach would be surgical excision followed by a non-weight-bearing cast for approximately four weeks. What other approaches could be considered? Due to her footgear, orthotics seem too far-reaching.
Barrett E Sachs, DPM, Plantation, FL
01/26/2010
QUERIES - (CLINICAL)
Query: Non-Specific Fibrosis
I have a 68 y/o overweight black female with 2 year history of relative asymptomatic, pedunculated skin of the bilateral lower legs, sparing the feet. The patient has 2+ non-pitting chronic lymphedema, otherwise PMH is non-contributory, All labs, including CMP, CBC, and thyroid were WNL.
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Non-Specific Fibrosis |
A biopsy revealed non-specific fibrosis. Numerous creams and compression have been utilized with minimal/no improvement. A dermatology consult was not helpful. Any thoughts on a curative treatment?
Mark Tracy, DPM, Port Charlotte, FL
01/20/2010
QUERIES - (CLINICAL)
Query: Hallux Limitus/Rigidus Implants
Approximately 6 months ago, I inserted an Arthrex- "Anatoemic Proximal Phalanx Hemiprosthesis" into a healthy and active 58 year old woman. The indications were moderately painful hallux limitus with degeneration of the proximal phalangeal articular surface and the dorsal fourth of the articular surface of the first metatarsal head - with DJD surrounding the periphery of the met head articular surface. Intra-operative ROM and correction were good. Presently, she complains of limited range of motion of the joint with pain (4/10), and discomfort in any shoe with more than a very slight heel raise. She now has 30 degrees active dorsiflexion/ 16 degrees plantarflexion of the MPJ.
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Hallux Limitus Implant |
After physical therapy, shoe modification, orthotics, topical and oral NSAIDs, and exhausting conservative treatment, I referred the patient to an orthopedist for a second opinion. He suggested several surgical options - preferring a fusion of the MPJ. What specific hemi or total first MPJ implant will gain the maximum range of motion in the MPJ? Would removing more of the proximal phalanx base and re-inserting the same implant create better ROM?
Craig Aaronson, DPM, Fresno, CA
01/19/2010
QUERIES - (CLINICAL)
Query: Corticosteroids
I am using dexamethasone phosphate when a fast-acting corticorsteroid is needed and Kenalog-10 for most other injections (heel, sinus tarsi, etc.) How would PM News readers compare these meds to others such as methylprednisilone 40 and 80, Celestone, dexamethasone LA? What are others using?
Michael Forman, DPM, Cleveland, OH
01/18/2010
QUERIES - (CLINICAL)
Query: Custom Orthoses vs OTC Study
In my studies as a podiatric resident, I have yet to encounter a solid, high level of evidence study strongly supporting the use of custom orthoses over pre-fab/OTC orthoses for the treatment of plantar fasciitis. Can anyone shed light on this?
Dan Preece DPM, PGY-1, Salt Lake City, UT
01/16/2010
QUERIES - (CLINICAL)
Query: Ankle Exostosis
I have a 52 year old active male patient who presented with pain over the tibial malleolus, 1-2 years in duration. Most of his discomfort occurs while skiing. Clinically, there is a considerable enlargement of the malleolus. X-rays show an enlarged distal fibula with hyperexostotic bone. The medial gutter of the ankle is not involved. There is no direct antecedent trauma, although a healing fracture is my number one rule out.
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Ankle Exostosis |
I gave him three options: 1. surgical remodeling of the distal tibial malleolus.2. A custom-molded ski boot 3. do nothing. Any other rule-outs on the exostosis of the ankle? Who would you refer him to for a custom ski boot with a cut-out for the tibial malleolus? Any other suggestons?
Michael Forman, DPM, Cleveland, OH
01/12/2010
QUERIES - (CLINICAL)
Query: DEXA Scans
Does anyone have any experience with DEXA bone density scans in-office for the calcaneus? Any recommendations on machines would be appreciated.
David Ellenbogen, DPM, NY, NY
01/01/2010
QUERIES - (CLINICAL)
Query: Bunion in 14 Year Old
My patient is a 14 year old volleyball player. He has a history of worsening bunions since childhood. The first ray is hypermobile with mild elevatus seen on the lateral view. The hallux is trackbound.
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Bunion in 14 Year Old |
This bunion looks worse clinically than radiographically. Note the increased PASA. I’m thinking about performing a Lapidus/Reverdin. Any thoughts or suggestions?
Chris Browning, DPM, Nederland, TX
12/31/2009
QUERIES - (CLINICAL)
Query: Glomus Tumor?
My patient is an 11 year old boy with "four month" development of tumor under his second toenail. There is no family history for tumors. He does not take meds and denies trauma. He complains of pain even at rest, which is worse with pressure.
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Glomus Tumor? |
X-rays taken reveal a well-defined, round, soft tissue silhouette of the mass sitting on the distal phalanx, causing sclerosis and scalloping of the cortex of the dorsal distal phalanx. I have ordered a contrasted MRI. I would appreciate any suggestions or treatment options.
Chris Browning, DPM, Nederland, TX
12/01/2009
QUERIES - (CLINICAL)
Query: Unilateral Spasm
The patient is a 14 y/o white female with a chief complaint of spasm in her right foot. She has a history of minor trauma (she fell after tripping over a stone). She presents wearing a CAM walker but is otherwise unassisted. Her spasm apparently initiated after the fall approximately one month ago. There was no spine injury or complaints. There was no laceration. Her medical history is remarkable for hemolytic uremic syndrome as an infant. She also has history of unexplained tremor 2 years ago which resolved spontaneously.
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Unilateral Spasm |
Her physical exam is unremarkable with exception of her right foot. The right hallux is rectus and extended but in spasm. The lesser toes are in extension. There is no erythema or edema. There is normal sensation to the toes. Vascular exam is normal. The extensor tendons are palpated and intact. Mild pain with palpation is elicited over the dorsum of the 1st metatarsal proximally. When she is distracted, the lesser toes and hallux can be manipulated into a corrected position. Radiographs and MRI are negative for tendon and/or joint pathology.
Initial impression was muscle spasm secondary to neuropraxia. Muscle relaxants were prescribed which were ineffective. Neurological consultation was obtained, results of which were unremarkable and inconclusive. I've entertained the idea of popliteal and common peroneal nerve block to assess whether or not the "spasm" would release. The patient is now two months post "injury" with no change in her foot "position." Her primary physician recalls that she has had some emotional issues in the past. My differential diagnosis includes conversion hysteria, neuropraxia or neurologic manifestation secondary to her history of HUS. I'm interested to know what others who read this post think or might suggest.
Thomas Graziano, DPM, MD, Clifton, NJ
