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Here is part 2 of our series in visual interpretation of findings on the lower extremity.
VERY IMPORTANT--
Look at the pictures below before you read anything. Write down what you see just as though this was a patient sitting in front of you for any exam. I found twelve issues. How many can you find?!!
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Visual examination of the pictures below reveals:
(How many of them did you spot?!)
1. 3rd (middle) toe erythematous and swollen. Possible infection secondary to the ulceration on the distal tip. (shown in 2nd picture)
2. Red spots on 5th toe, proximal joint of 2nd toe and medial area of Hallux interphalangeal joint. Probably secondary to shoe pressure.
3. 2nd toe with distal hyperkeratotic lesion secondary to hammertoe deformity. Dark staining in the lesion probably dried blood.
4. Brownish discoloration on forefoot just proximal to toes. Could be signs of venous stasis.
5. Thin, atrophic, hairless skin. Indicates arterial insufficiency.
6. Possible maceration deep in innerspace between second and third toes.
7. Contracted digits "Hammertoes" on toes 2 thru 5.
8. Bony prominence at Hallux interphalangeal joint. Possibly degenerative arthritis.
9. Full thickness ulceration distal tip third toe.
10. Thick, dystrophic toenails 1 - 5
11. Dry skin on lateral plantar forefoot, proximal to 5th toe. Possibly tinea pedis.
12. Severe orthopedic deformities. May indicate motor neuropathy, injury, congenital malformation. Clues from patient history
Same Foot
Dorsal and Plantar Views
Treatment Plan: Certainly the most important issue is the red, swollen third toe. We can see that the problem is the full thickness ulceration on the distal tip of the toe. At this point in time the erythema is limited to the toe only. It does not extend on to the dorsum of the foot. The care that you provide depends on your setting. What I mean is ... are you seeing this patient in a clinic, a retirement home, as senior center, a family group home, etc? If you are working at a senior center or retirement home, you are without clinic resources and your goal is to clean and dress the ulcer the best way you can and immediately refer the patient to his/her podiatrist or family practitioner for definitive care. And you need to truly communicate the extremely serious nature of the ulcer and infection so that the patient understands the urgency of seeking further care. Realizing that the ulcer is in a location where the patient can't see it so this is all news to them. If you are in as clinic setting you need to provide definitive care to prevent this infection from progressing. You first need to take a thorough patient history. Previous ulcers or infections, diabetes and other comorbidities, medications, etc. Take the vitals, including temperature, BP and blood sugar if the patient is diabetes. Remember that many high risk patients don't mount the same signs of infection as others. So it may be misleading that the erythema is limited to just the toe. Variances in some of the vitals can be your indication of a more severe infection. It may be premature to do blood work. But that's a consideration also. For treatment of the lesion, after thorough cleansing and debridement (if necessary) you might consider a silver dressing. It doesn't need to be an absorptive dressing as these distal tip ulcers are generally not too exudative. And very importantly the patient needs to be put in accommodative shoe gear of some sort to relieve the pressure on the toe. I wouldn't suggest starting the patient on oral antibiotics at this point. (unless other factors indicate it) With impaired circulation, the antibiotics often don't reach the tissues in the lower extremity in a high enough concentration to be effective. And, of course, we're all aware of the general overuse of antibiotics. You need to educate the patient on signs of increasing infection so that they can seek care immediately if the condition worsens. I would schedule them to come back to clinic in about 3 days. We need to evaluate the progress of the infection and we need to evaluate the effectiveness of the offloading shoe/padding. After this current situation is resolved, don't forget to work with the patient to assure that steps are taken to prevent recurrence of the ulceration. Shoe gear changes, accommodative/protective padding on the toe and surgical correction of the hammertoe are among the options. | 
