Patient Case

[Dr Hurly MD]

ANY patient with a PMH of 1) diabetes mellitus, 2) hallux limitus/rigidus, and 3) onychauxis of the hallux digit should watch out for this PRIMARY disease....

No it is not psoriasis. No it is not hemochromatosis. Try again podiatry externs

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[Ferocity]

Prostatitis.

 

[Dr Hurly MD]

Prostatitis.

NO

Let's paraphrase, hopefully making it more easier:

ANY diabetic adult with a hallux digit that shows on clinical exam onychauxis and hallux limitus/rigidus. What primary disease should you warn the patient about as being a great risk in the near or distant future based on such a PMH?

 

[backrowH20]

this is not a primary disease, but i thought i would add it to the list of possibilites

Osteomyelitis.... due to increased pressures to the distal plantar hallux which will cause increase hpk tissue which untreated will cause tissue breakdown underlying it. and if cont to be untreated could breakdown to where bone infection manifest.

 

[Dr Hurly MD]

this is not a primary disease, but i thought i would add it to the list of possibilites

Osteomyelitis.... due to increased pressures to the distal plantar hallux which will cause increase hpk tissue which untreated will cause tissue breakdown underlying it. and if cont to be untreated could breakdown to where bone infection manifest.

You are a very bright podiatry student I see. But you went a step too far. Osteomyelitis indeed is a secondary disease (like you stated) that happens when this primary disease I am looking for is not treated promptly.

 

[Dr Hurly MD]

this is not a primary disease, but i thought i would add it to the list of possibilites

Osteomyelitis.... due to increased pressures to the distal plantar hallux which will cause increase hpk tissue which untreated will cause tissue breakdown underlying it. and if cont to be untreated could breakdown to where bone infection manifest.

HINT: What is another name for the statement in boldtype?

 

[backrowH20]

HINT: What is another name for the statement in boldtype?

Abscess?

 

[Dr Hurly MD]

Abscess?

No. Try again. I will give you all 3 more attempts. If wrong on the 3rd try, then I will give the right answer.

 

[Sig Savant]

Charcot?

 

[ucdgogie]

I know im only a first year but after reading this the first thing that came to my mind is diabetic ulcers. Because of the extra pressure on the hallux, plus a possibility of diabetic neuropathy. i am not exaclty sure how the onychauxis fits into the possibility of future ulcers. only thing i could think of is it becomes more difficult for the patient to cut their thicker nails and they are more likely to cut them selves and because of their neuropathy wouldnt notice it. also with your hint above, osteomyelitis is a possible secondary disease to diabetic ulcers.

 

[Sig Savant]

Onychauxis seems to be caused by a problem with vasculature.. so microcirculation? In diabetes, there are problems with microcirculation..For instance you can have a strong dorsalis pedis pulse but still develop an ulcer plantarly just a few cm away because the microvasculature has a problem. That is my guess at the tie between diabetes and onychauxis.

 

[Dr Hurly MD]

I know im only a first year but after reading this the first thing that came to my mind is diabetic ulcers. Because of the extra pressure on the hallux, plus a possibility of diabetic neuropathy. i am not exaclty sure how the onychauxis fits into the possibility of future ulcers. only thing i could think of is it becomes more difficult for the patient to cut their thicker nails and they are more likely to cut them selves and because of their neuropathy wouldnt notice it. also with your hint above, osteomyelitis is a possible secondary disease to diabetic ulcers.

For a first year podiatry student, YOU ARE CORRECT! Bravo! The answer I am looking for is SUBUNGUAL ULCERATION.

Here is another quiz: let's say the subungual ulceration is CLEAN (not infected, i.e.: no cellulitis, no lymphangitis, no necrotizing fasciitis, no osteomyelitis), but NOT HEALING after 6 months of treatment? What disease do you as a podiatric physician have to worry about now which is just as deadly as an infection?

 

[PADPM]

For a first year podiatry student, YOU ARE CORRECT! Bravo! The answer I am looking for is SUBUNGUAL ULCERATION.

Here is another quiz: let's say the subungual ulceration is CLEAN (not infected, i.e.: no cellulitis, no lymphangitis, no necrotizing fasciitis, no osteomyelitis), but NOT HEALING after 6 months of treatment? What disease do you as a podiatric physician have to worry about now which is just as deadly as an infection?

Subungual melanoma.

 

[PADPM]

I'm not sure that I would call an ulceration a "primary disease" An ulceration is a manifestation of an underlying problem such as PVD, diabetes, diabetes with PVD, mechanical trauma, a combination of the above, etc. But is an ulceration considered a primary "disease"????

For example, a patient can have an esophageal ulcer, but that is a manifestation of a disease process. The PRIMARY disease would be GERD or some other etiology.

 

[Dr Hurly MD]

subungual melanoma.

no

 

[Dr Hurly MD]

I'm not sure that I would call an ulceration a "primary disease" An ulceration is a manifestation of an underlying problem such as PVD, diabetes, diabetes with PVD, mechanical trauma, a combination of the above, etc. But is an ulceration considered a primary "disease"????

For example, a patient can have an esophageal ulcer, but that is a manifestation of a disease process. The PRIMARY disease would be GERD or some other etiology.

SIGH ....NO

 

[PADPM]

no

No???? That may not be the answer YOU are looking for, but it's a correct answer. A non healing wound on a nail bed, that presented as a subungual ulcer can absolutely be a subungual melanoma, which is MORE deadly than an infection.

Squamous cell carcinoma can often be found in a non healing ulcer which is often associated with osteomyelitis, but subungual melanoma may not be what YOU were looking for, but it's a completely valid and correct answer.

And instead of showing an icon sleeping, I'm wondering why you didn't address the statement I made. You stated that an ulcer was a primary disease and I disagree. Your thoughts?

 

[Dr Hurly MD]

No???? That may not be the answer YOU are looking for, but it's a correct answer. A non healing wound on a nail bed, that presented as a subungual ulcer can absolutely be a subungual melanoma, which is MORE deadly than an infection.

Squamous cell carcinoma can often be found in a non healing ulcer which is often associated with osteomyelitis, but subungual melanoma may not be what YOU were looking for, but it's a completely valid and correct answer.

And instead of showing an icon sleeping, I'm wondering why you didn't address the statement I made. You stated that an ulcer was a primary disease and I disagree. Your thoughts?

Where are my podiatry students?

 

[PADPM]

Dr., I posed a valid question to you as well as a valid answer to your question. I'm not sure why you keep reverting to childish icons and instead of having a mature and professional reply to my questions.

I find it strange that you, as a medical professional would choose to not answer valid concerns.

 

[Dr Hurly MD]

Dr., I posed a valid question to you as well as a valid answer to your question. I'm not sure why you keep reverting to childish icons and instead of having a mature and professional reply to my questions.

I find it strange that you, as a medical professional would choose to not answer valid concerns.[/QUOT

-First of all, they are not icons. They are called EMOTICONS.
-Second of all, if these emoticons were 'childish', then why are they in SDN in the first place?
-Third of all, what I meant by 'primary' was not a disease process as you mentioned...I meant 'the top most likely' disease in the DDx.
-Fourth of all, there is nothing subungual involved. Treating the ulcer on the nailbed hallux digit would require total avulsion of the hallux nailplate first.
-FIfth of all, melanoma is not the main top priority risk factor in this case compared to what I am looking for....

But anyway, the 'top most likely' disease I was looking for on the DDx in this case was BASAL/SQUAMOUS CELL CARCINOMA. ALL unhealed uninfected chronic skin wounds and skin ulcers in the lower extremity are at risk for basal/squamous cell carcinoma, a very vital important goal that wound care podiatrists should keep in mind of. The last thing to happen is to have a dermatologist and an oncologist hop on board.

 

[PADPM]

I thank you for your reply.

1) As far as the emoticons, I have no idea why they exist on SDN. I don't own the site.

2) NOW I understand your use of the word "primary", but certainly you can understand how I interpreted the terminology "primary disease".

3) I'm afraid that you may be contradicting yourself. You stated "fourth of all there is no subungual involved". Yet in your response to ucdgogie, YOU stated "the answer I am looking for is SUBUNGUAL ULCERATION."

4) YOU stated again stated SUBUNGUAL ULCERATION, and then asked what could be the etiology of a non healing wound bed, with significant potential consequences

5) Therefore, I answered subungual melanoma, which would always be suspected in this scenario.

6) If you read my response, I also mentioned squamous cell carcinoma, which clinically should always be expected in a non healing wound, especially in the presence of osteomyelitis.

7) So my answer was based on your stating that the dx was subungual ulceration.

 

[347932]

But anyway, the 'top most likely' disease I was looking for on the DDx in this case was BASAL/SQUAMOUS CELL CARCINOMA. ALL unhealed uninfected chronic skin wounds and skin ulcers in the lower extremity are at risk for basal/squamous cell carcinoma, a very vital important goal that wound care podiatrists should keep in mind of. The last thing to happen is to have a dermatologist and an oncologist hop on board.

Wow, huh?

I have to intervene here.

So for anyone with diabetes, hallux limitus and onychauxis we should be concerned for the above DDx????

I work in a major wound care center and have seen plenty of the above and have NEVER encounter this, with the hundreds of recalcitrant ulcerations I've seen and successfully healed. I'm sorry, but the DDx you were looking for has distinct signs to look for and are somewhat of "zebras", not horses.

I've followed this thread closely to see what in the world you were eluding to and am mystified by your approach.

Your methods in this thread are WAY off. And no, if someone is concerned with the above, it is imperative to BIOPSY if there are suspicions. THEN get others involved if necessary and a diagnosis is verified.

Not only that, but it is just as likely in a non diabetic, without hallux limitus, so why even mention those diagnoses? Statistically, it is actually MORE likely in a non diabetic without hallux limitus. ESPECIALLY with basal cell, which isn't a converting type skin ulcer. Having a chronic ulcer is much more likely to convert to Squamous cell, whereas Basal Cell is more likely a primary ulceration and not due to chronicity.

Sorry Dr. Hurly. This time, you may want to not give someone a hard time when they are absolutely right.

 

[Dr Hurly MD]

Wow, huh?

I have to intervene here.

So for anyone with diabetes, hallux limitus and onychauxis we should be concerned for the above DDx????

I work in a major wound care center and have seen plenty of the above and have NEVER encounter this, with the hundreds of recalcitrant ulcerations I've seen and successfully healed. I'm sorry, but the DDx you were looking for has distinct signs to look for and are somewhat of "zebras", not horses.

I've followed this thread closely to see what in the world you were eluding to and am mystified by your approach.

Your methods in this thread are WAY off. And no, if someone is concerned with the above, it is imperative to BIOPSY if there are suspicions. THEN get others involved if necessary and a diagnosis is verified.

Not only that, but it is just as likely in a non diabetic, without hallux limitus, so why even mention those diagnoses? Statistically, it is actually MORE likely in a non diabetic without hallux limitus. ESPECIALLY with basal cell, which isn't a converting type skin ulcer. Having a chronic ulcer is much more likely to convert to Squamous cell, whereas Basal Cell is more likely a primary ulceration and not due to chronicity.

Sorry Dr. Hurly. This time, you may want to not give someone a hard time when they are absolutely right.[/QUOTE

Sorry Kidsfeet, but this post makes no sense.
-First of all, the ulcer in your case never became a carcinoma because according to you it healed. Hence how can the ulcer be called recalcitrant (meaning, it NEVER healed)? A contradiction.
-Second of all, it is a horse, because there are plenty of EBM that shows that when you have a poorly treated hallux limitus/rigidus, onychauxis, and diabetes together, you will get a subungual ulceration, a COMMON CLINICAL COMPLICATION. The other common clinical complication is a painful tyloma under the hallux interphlangeal joint (IPJ). And a third common complication is IPJ osteoarthritis.
-Third of all, a non diabetic with a PMH of hallux limitus/hallux rigidus and onychauxis will have a lower probability of getting a subungual ulceration because such patients do not have the risk factor of vasculopathy, immunopathy, and neuropathy like the diabetic does which leads to poor healing potential from microtrauma of the subungual nailbed.
-Fourth of all, the EBM shows that BASAL CELL AND SQUAMOUS CELL CARCINOMA can occur in unhealed chronic uninfected skin wounds and ulcer wounds in the human body, particularly the lower extremity.
-Fifth of all, of course you do a biopsy, That is a given in the face of a recalcitrant skin wound that is not healing.

 

[janV88]

Uhhh...Subungual ulceration is NOT a PRIMARY disease.

My answer, Hemochromatosis, can cause diabetes (while mimicking the symptoms of DM) and arthritis as well as being a primary disease.

 

[Dr Hurly MD]

Uhhh...Subungual ulceration is NOT a PRIMARY disease.

My answer, Hemochromatosis, can cause diabetes (while mimicking the symptoms of DM) and arthritis as well as being a primary disease.

Like I said before, in the context of the first post...the answer to you is NO. And by the word 'primary', I meant on top of the DDx in the context of the first post in this thread. It has nothing to do with a disease process. Only in terms of most likely on top of the DDx. So no, your answer is not top bidding (ie. primary disease) on the DDx for the first post.

CLINICAL PEARL:

Diabetes mellitus + hallux limitus/rigidus + onychauxis of hallux digit = 1) subungual ulceration (primary disease ON THE DDx)

 

[G0dFather]

You are great ... please continue to post more educational scenarios like this ... im sure many more of us totally appreciate them!

Like I said before, in the context of the first post...the answer to you is NO. And by the word 'primary', I meant on top of the DDx in the context of the first post in this thread. It has nothing to do with a disease process. Only in terms of most likely on top of the DDx. So no, your answer is not top bidding (ie. primary disease) on the DDx for the first post.

CLINICAL PEARL:

Diabetes mellitus + hallux limitus/rigidus + onychauxis of hallux digit = 1) subungual ulceration (primary disease ON THE DDx)

 

[trinifootdoc]

You are great ... please continue to post more educational scenarios like this ... im sure many more of us totally appreciate them!

You are so right! I like posts like this. My roommate and I, both first year students, were trying to figure it out. It is very intellectually stimulating. Please keep these coming.

 

[janV88]

Yes these case studies are very intellectually stimulating. It gets students to think more thoroughly about the disease processes going on. But in this case, you are not using the term "primary disease" correctly. Subungual ulceration is not a primary disease.

And if you meant "more likely" then toe nail fungus would probably be more likely than subungual ulceration.

 

[Dr Hurly MD]

Yes these case studies are very intellectually stimulating. It gets students to think more thoroughly about the disease processes going on. But in this case, you are not using the term "primary disease" correctly. Subungual ulceration is not a primary disease.

And if you meant "more likely" then toe nail fungus would probably be more likely than subungual ulceration.

Yes you are right. I used the wrong word that caused the misunderstanding. Primary is not a good word to use. Sorry, but onychomycosis is not the right answer either in this case. But I like your thinking because onycomycosis is possible with a diabetic with low healing potential and immunopathy.

But keep that clinical pearl in mind in your future practices all of you podiatry students. You are bright thinkers and you will do fine with allopaths and osteopaths your age.

 

[dtrack22]

Yes these case studies are very intellectually stimulating. It gets students to think more thoroughly about the disease processes going on. But in this case, you are not using the term "primary disease" correctly. Subungual ulceration is not a primary disease.

And if you meant "more likely" then toe nail fungus would probably be more likely than subungual ulceration.

These cases would be even more stimulating it the person presenting was actually asking the right questions/using correct verbiage.

With all that said, I clearly need to get back to my readings/lectures. I missed the part where subungual ulceration would be on the top of my ddx in this patient

 

[347932]

-Second of all, it is a horse, because there are plenty of EBM that shows that when you have a poorly treated hallux limitus/rigidus, onychauxis, and diabetes together, you will get a subungual ulceration, a COMMON CLINICAL COMPLICATION. The other common clinical complication is a painful tyloma under the hallux interphlangeal joint (IPJ). And a third common complication is IPJ osteoarthritis.
Citations please.

-Fourth of all, the EBM shows that BASAL CELL AND SQUAMOUS CELL CARCINOMA can occur in unhealed chronic uninfected skin wounds and ulcer wounds in the human body, particularly the lower extremity.

Of course they CAN. Doesn't mean it's remotely common.
Citation please.

You mention EBM, but offer no citations. If this is a clear case of EBM, provide links to the appropriate literature so we can all learn from it.

 

[347932]

These cases would be even more stimulating it the person presenting was actually asking the right questions/using correct verbiage.

Exactly.

 

[Sig Savant]

An unhealed ulcer present for more than six months can develop into a Marjolin's ulcer (squamous cell carcinoma) due to rapid division of cells in the area.

 

[Dr Hurly MD]

-Second of all, it is a horse, because there are plenty of EBM that shows that when you have a poorly treated hallux limitus/rigidus, onychauxis, and diabetes together, you will get a subungual ulceration, a COMMON CLINICAL COMPLICATION. The other common clinical complication is a painful tyloma under the hallux interphlangeal joint (IPJ). And a third common complication is IPJ osteoarthritis.
Citations please.

-Fourth of all, the EBM shows that BASAL CELL AND SQUAMOUS CELL CARCINOMA can occur in unhealed chronic uninfected skin wounds and ulcer wounds in the human body, particularly the lower extremity.

Of course they CAN. Doesn't mean it's remotely common.
Citation please.

You mention EBM, but offer no citations. If this is a clear case of EBM, provide links to the appropriate literature so we can all learn from it.

I find your remarks in red type very disturbing and makes me suspicious of your EBM prowess. You simply need to keep up with your reading of the updated and old EBM in the form of textbooks and peer reviewed clinical journals. I do not think you have. CME conferences may or may not help. But the EBM is out there, vast and intimidating as it is.

I know the EBM citations for this topic. But the EBM for you: Use it, find it, and read it. The citations are out there. I do not spoon-feed other physicians. It is setting a bad example for the students.

 

[347932]

I find your remarks in red type very disturbing and makes me suspicious of your EBM prowess. You simply need to keep up with your reading of the updated and old EBM in the form of textbooks and peer reviewed clinical journals. I do not think you have. CME conferences may or may not help. But the EBM is out there, vast and intimidating as it is.

I know the EBM citations for this topic. But the EBM for you: Use it, find it, and read it. The citations are out there. I do not spoon-feed other physicians. It is setting a bad example for the students.

Please. If you're trying to educate you SHOULD provide the citations. Otherwise, you can spew any drivel you want and say "It's there, YOU find it". I taught EBM and literature review at a major medical institution and helped devise a curriculum at that institutions for the attendings concerning the topic.

Your mildly condescending tone is having me start to question who you are. Caddypod?

 

[PADPM]

I find your remarks in red type very disturbing and makes me suspicious of your EBM prowess. You simply need to keep up with your reading of the updated and old EBM in the form of textbooks and peer reviewed clinical journals. I do not think you have. CME conferences may or may not help. But the EBM is out there, vast and intimidating as it is.

I know the EBM citations for this topic. But the EBM for you: Use it, find it, and read it. The citations are out there. I do not spoon-feed other physicians. It is setting a bad example for the students.

Really? The way to combat Kidsfeet's request for EBM to back your claims is to tell him it's out there but he'll have to find it????!!!!!!

Doesn't exactly lend credibility to your claims. Your insult is actually embarrassing. I'm confident that Kidsfeet as well as virtually every other poster on this site is fully capable of searching for the evidence, but YOU are the one who was asked to provide the EBM to support your comments.

So don't turn the tables, it's an obvious deflection.

 

[Dr Hurly MD]

Really? The way to combat Kidsfeet's request for EBM to back your claims is to tell him it's out there but he'll have to find it????!!!!!!

Doesn't exactly lend credibility to your claims. Your insult is actually embarrassing. I'm confident that Kidsfeet as well as virtually every other poster on this site is fully capable of searching for the evidence, but YOU are the one who was asked to provide the EBM to support your comments.

So don't turn the tables, it's an obvious deflection.

You and Kidsfeet bend over....I need to check a vital sign: who am I? it's you know who...

http://www.youtube.com/watch?v=u_FNw83T8Cw

 

[PADPM]

You and Kidsfeet bend over....I need to check a vital sign: who am I? it's you know who...

http://www.youtube.com/watch?v=u_FNw83T8Cw

Exactly what I expected from you.....completely avoiding the questions posed.


Your credibility-----ZERO

 

[dyk343]

Why does every thread turn into a pissing match?

I remember when the SDN forums were where people went to learn about and discuss important topics in podiatry... now its just a waste of time with internet tough guys.

 

[Ankle Breaker]

Why does every thread turn into a pissing match?

I remember when the SDN forums were where people went to learn about and discuss important topics in podiatry... now its just a waste of time with internet tough guys.

Prob why Feli, Krabmas, Jonwill, Podfather, and Natch don't post anymore. Not worth it.

 

[Dr Hurly MD]

Prob why Feli, Krabmas, Jonwill, Podfather, and Natch don't post anymore. Not worth it.

And I am joining them. I agree. Not worth it.

 

[dyk343]

Prob why Feli, Krabmas, Jonwill, Podfather, and Natch don't post anymore. Not worth it.

Your forgot Dr. Lee C. Rogers.

 

[347932]

Why does every thread turn into a pissing match?

I remember when the SDN forums were where people went to learn about and discuss important topics in podiatry... now its just a waste of time with internet tough guys.

You're absolutely right!

We should just get spoon fed information and accept it to be true whether it is or not. Sorry to challenge the status quo, there. Or would you rather just get misleading information from a troll without question?

If the perception is that this is a pissing match, you need to open your eyes.

 

[347932]

Prob why Feli, Krabmas, Jonwill, Podfather, and Natch don't post anymore. Not worth it.

Or maybe they're so disgusted by some of the behavior they see (I'm speaking about my atrocious behavior, of course) and the disrespect some get they don't want to get involved? It seems like the longer people are in practice around here the bigger the target on their backs get (What disease process causes that again???).

Or maybe they get angry when they realize that they try to help (I'm such a miserable SOB, I know) and get smeared for their efforts?

That's Bruce Ward....errrr....Robin talking. To the Batmobile!!!!

 

[347932]

Your forgot Dr. Lee C. Rogers.

You're right again!! Rather than focus on his congressional campaign, he should be defending his honor against a troll!!!! What a great way to spend (waste...oops did I actually write that!) his time!!!

 

[347932]

And I am joining them. I agree. Not worth it.

Don't let the door hit you in the ***.

 

[Dr Hurly MD]

You are great ... please continue to post more educational scenarios like this ... im sure many more of us totally appreciate them!

Well, Kidsfeet and PADPM say I am not great. I am not coming back anymore. Anything I or any other fellow allopath or osteopath presents here on Podiatry SDN has to be citated. So just learn clinical pearls from them. They are great (according to them, and they do not need a citation for that).

 

[347932]

Well, Kidsfeet and PADPM say I am not great. I am not coming back anymore. Anything I or any other fellow allopath or osteopath presents here on Podiatry SDN has to be citated. So just learn clinical pearls from them. They are great (according to them, and they do not need a citation for that).

Where did I say that????

When you start preaching EBM, you better be damn straight on it. Citations REQUIRED.

Again, don't let the door hit you in the ***.

 

[Dr Hurly MD]

Where did I say that????

When you start preaching EBM, you better be damn straight on it. Citations REQUIRED.

Again, don't let the door hit you in the ***.

Podiatry students: see what I mean? Citations required actually means Kidsfeet forgot his clinical sciences and wants me to spoon-feed, be baby-sit, and review for him what he simply does not know from the clinical thread here. You podiatry students are clearly smarter than Kidsfeet and PADPM. If they both post otherwise, they are insulting all of you. At least you students can look up the EBM yourself and not be spoon-fed because of lack of clinical knowledge prowess and the independence to self learn.

Rather for Kidsfeet and PADPM, take the easy short cut and simply say "cite the EBM (so I do not waste my time doing it myself because I am lazy)" and use reverse psychology tactics. I mean, why are you pod students wasting your time on this Podiatry SDN? Leave like I am. You won't regret it. You are way too smart for this place, a place only for smart-ASSES.

 

[Creflo]

To the OP, I like the discussion. I quit reading after it turned into a pissing match, but originally I found it to be a good discussion. We need more stuff like this on the forum. I see the icons as fun. This can be a great place to bounce ideas off each other and help each other learn.