A Repeat Patient Case

Discussion in 'Podiatric Residents & Physicians' started by Sig Savant, Apr 9, 2012.

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  1. Sig Savant

    Sig Savant 2+ Year Member

    Aug 12, 2008
    Terre Haute
    The other day, I'm seeing a diabetic patient in clinic, and they have onychauxis. Then I see that they also have Hallux Limitus - Dr Hurly pops into my head - check for subungual ulceration! Well that case turns out to be nothing...

    But just today I am reading Podiatry Today - March 2012 - How to Address Onychomycosis in Patients with Diabetes - and behold page 2 discusses: "If the patients are fortunate, one will discover the ulcer at the time of the regular debridement of the nail but this happens if and only if the caseous material of an onychomycotic nail receives aggressive debridement. The physician who decides to limit his or her debridement to the length of the nail and top several layers of onychomycotic nail may miss the presence of an ulceration completely.
    Another clue to the presence of a subunugal ulceration in a patient with diabetes is the presence of hallux limitus with a thickened nail. Boffeli and colleagues found this biomechanical abnormality along with the deforming nail to have caused four uclers. "

    There you have it - while it isn't peer reviewed, Drs. Brett Waverly and Kathleen Satterfield agree that thickened nails in diabetics with hallux limitus should be carefully watched for ulcers developing under the hallux nail. In order to find this, though, you must debride enough of the nail to see it.

    -Boffeli, Bean, natwick. Biomechanical abnormalities and ulcers of the great toe in patients with diabetes. JFAS 2002; 41(6): 3359-364.
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  3. I don't know. I just haven't seen it.

    One study suggesting it doesn't make it a common occurrence imo.

    HOWEVER, you should ALWAYS be diligent with your diabetic patients that you see for their at risk foot care. Don't mindlessly "cut toenails". A thorough inspection of these peoples' feet should be done on every visit. THAT is really why they are there to see you, isn't it?
  4. AttackNME

    AttackNME Podiatrist 10+ Year Member

    Feb 22, 2007
    A search for "subungual ulceration" on pubmed doesn't reveal much, but it does make sense: hallux limitus increases hallux pressure/strain through a longer lever arm or a bigger abductory twist. Add in onychauxis, and it sets up the hallux nail to rub hard against the shoe increasing chances of a subungual ulcer. It may heal without incidence by staying a closed ulcer... however it may get infected if you debride aggressively and create an open ulcer. Obviously I'll look into it if distal to hallux IPJ is red hot swollen and painful, but I'm gonna follow the rule of "If it ain't broke don't fix it."
    Last edited: Apr 10, 2012

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