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Post by hurleygirly on Sept 24, 2008 19:57:30 GMT
Hi all, Have a regular customer with a fairly standard HM between 4/5, which is becoming more painful between visits. Does anyone have any tips with regards to treatment? This patient is happy to pay about 5 times a year to have it enucleated, but the time between visits is getting shorter. I understand the most basic basic biomechanics, and have advised that for long term relief she needs to address the cause...but she fights me all the way. I have tried ottoform, gel dividers etc, but she complains that she can't keep them in, and as she has had a hip replacement, getting down there to adjust it/put it in is just too much of a job. Her lovely husband wonders if there is a cream that might halt the formation, which he will gladly administer.. Karen X
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Post by robertisaacs on Sept 25, 2008 7:56:50 GMT
I am not the best person to ask about this, i've not done much proper podiatry in the last 5 years. However i do have a trick which has worked quite well before. Bit technical. Basically i find that the proliferation of macerated tissue is usually secondary to two factors, exogenic and endogenic. The environment between the toes is, of course, usually quite moist meaning that osmotic pressure gradients cause transition of water into skin cells and the turgidity and lysis of these cells cause hyperproliferation in the growth layer. However the shearing stress caused by increased friction secondary to the closer adhesion of the skin between toes can also cause endogenic increases in moisture in the form of deep blistering and this can cause as much trouble. I don't find silicon wedges help much as although they reduce movement they can still allow considerable pressure and moisture to be present. I favour a wicking medium applied and frequently refreshed to switch the osmotic gradient and reduce both exo and endogenic mosture and thus reduce the tendancy of the skin to hyperproliferate. Or, in short terms. bung a good sized lump of cotton wool between the toes held in by a strip of micropore top and bottom. Get the patient to replace this 3 times a day minimum, morning luchtime and evening. When the skin has dried i then use an antifungal powder as well to keep friction down. I'm sure someone will be along with a better idea soon. Robert
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Post by twirly on Sept 25, 2008 10:02:07 GMT
Hello Hurley & Robert, ;D A few years ago I was fortunate to have worked with the Podiatry surgery team in Doncaster. One of the procedures performed on recalcitrant I/D H/molle was Syndactylyation (I hope Bill will correct my terminology if it is dodgy) Interdigital skin is removed from opposing digits & the wound edges are then closed making the toes perform as a single digit. The few procedures I saw performed I understand were a success. I will search for some references as Ms. Google has sadly not performed well in this particular instance. A Podiatry surgery tome may reveal more relevant data. Not as classy as your cotton wool procedure Robert but I cant touch the stuff! It squeaks you know. Argh!
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Post by billliggins on Sept 25, 2008 11:01:32 GMT
Hello Twirly
Syndactylisation is indeed a procedure which can be used in this situation. However, as an avid follower of the KISS (keep it simple, stupid) philosophy, I've always found that an arthroplasty works well. The head of the proximal phalanx of either the 4th or 5th toe (HM are usually found ID 4/5) is removed. The shearing which Robert mentions is immediately stopped since the relevant toe is now shortened and the relationship between the joints altered.
Always worth trying Robert's trick to avoid surgery, or in some cases of excessive STJ pronation appropriate orthoses may do the necessary. Horses for courses.
All the best
Bill
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Post by hurleygirly on Oct 9, 2008 11:29:00 GMT
Thanks all for your words of wisdom. She's not that damp 'tween toes, quite dry actually, so giving the cotton wool idea a miss. Did discuss the other procedures mentioned, but an article in the Daily Mail that came out last week regarding treatment prices for 'corn removal' (£4,000? ??) put her off doing anything other than palliative care!! So I keep my regular customer We are now using digital tips with the ends cut off which her husband puts on each morning. Worth a try. Thanks anyway all, Karen X
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Post by blinda on Oct 9, 2008 11:38:34 GMT
Hi Karen,
As you know all corns are caused by pressure (except the viral ones of course ;D)
Might be worth measuring her feet....pts are often wearing shoes 1 or even 2 sizes too small!
Cheers, Bel
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Post by robertisaacs on Oct 9, 2008 19:07:00 GMT
;D ;D ;D
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Post by hurleygirly on Oct 10, 2008 8:01:16 GMT
Hee Hee!!
She did ask me to make sure I "dug out the root"....is this from the same article as the viral corn masterpeice?
Maybe she just needs to change her choice of daily rag, and all will be well!!
Karen X
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Post by robertisaacs on Oct 10, 2008 11:25:59 GMT
Silly patient. Everybody knows you don't DIG corn roots out. You SUCK them out ;D.
Or use marigold. That eats into the stalk. ;D
Regards Robert
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Post by chifhpod on Oct 11, 2008 12:34:57 GMT
Hi Karen,
Enucleate the HM and wet the skin with surgical spirit (not water - important!). Briefly apply a silver nitrate applicator. Do this each time you see the patient. Needs no dressing whatever so compressive pressure is not increased.
The HM will become less painful and less deep and will disappear over a medium term.
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Post by ianl on Oct 11, 2008 14:41:34 GMT
Hi
Have to say that the bit that interests me is "..but she fights me all the way." Even if you off loaded biomechanically I suspect she would find a problem.
Ian
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Post by blinda on Oct 11, 2008 16:32:48 GMT
This could work well to treat symptoms in a healthy individual, ie no PVD, PAD, peripheral neuropathy, ischaemia or immunocompromisation (is that a word? Well you know what i mean) etc, you don`t wanna delay/compromise healing. But this does not address cause of the HD.
Cheers, Bel
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Post by dtt on Oct 12, 2008 15:41:24 GMT
Hi Bel et al Remove the cause EFFECT A CURE I use that maxim in practice wherever possible Always worth the extra effort in RX & Tx Cheers Derek
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Jude
New Member
Posts: 47
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Post by Jude on Nov 23, 2008 0:37:38 GMT
Hi Karen I've always found that a little granuflex is great other alternatives are comfeel, newer dressings alevyn thick and thin secured with a bit of tape. These are useful dressings for ulcerations and can be left on for up to a week and my patients have no problem having a bath with them on. Although some patients cannot tolerate even these dressing so use your common sense and say to them to remove if they feel it draws.
Ultimately you should be looking for the cause of the problem questioning onset, footwear and socks not forgetting the elastic sort, biomechanical issues and patients general health which should cover circulation and immune diff disorders.
Hope this helps Jude
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ipod
Junior Member
Posts: 55
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Post by ipod on Nov 23, 2008 18:50:57 GMT
Having read the previous posts I would like to offer my experience with some of these.
Silver nitrate is a definate no no for me these days, since one of my patients developed a nasty ulcer as a direct result. It healed well and in fact did her a favour, but when she rang me in a panic, I went to visit and got a speeding ticket on the way!
Granuflex is also one to be careful with- if there is any infection in a soft corn that has broken down, it will provide an occlusive environment and allow the bugs to breed! Also had experience of this in my early days.
Offloading is surely a good option, however, most of the patients I see with this problem have a classic burrowing 5th toe that wants to sit tight against the 4th toe. In my experience, the best method of prevention is to make a small ID wedge out of silicone which is hard wearing and very easy for the patient to use.
I am sure that other posters will have other positive input.
Ipod
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