X-rays usually show items with metallic content or dense.  Pyogenic granuloma is something I’ve seen previously. Although foreign body must be ruled out, in addition to neoplastic skin lesion.

Simon Young, DPM
Simonyoung@juno.com

Differentials:

1. Foreign Body Inclusion - Possibly glass since X-ray unremarkable.
2. Localized Abscess at puncture sight
3. Would not discount that there could have been an ulceration or cancerous lesion at site previously due to fact that she is poor historian

Next step:

1. Find out patients vitals, CBC/diff, blood cultures

2. I & D of heel with exploration for foreign body
   

Kent Stahl, DPM PGY2
kentstahl@sbcglobal.net

Here's my primary differential for the nonhealing ulceration in this case:

Traumatic

Retained underlying foreign body w/ or w/o granulomatous and/or associated cellulitis (the diffuse ankle edema)- possible with this history.

Decubitus ulcer - unlikely based on the location Vascular

Ischemic - unlikely since she has palpable pulses and the wound is hemorrhagic.

Vasculitic- possible.

Embolic - more likely if recent surgery.

Thromboangiitis obliterans - maybe. Is she a smoker?

Pyoderma gangrenosum - highly unusual location for this.

Neurologic

Neuropathic ulcer - (whether from ETOH, DM or other) - doesn't have quite the hyperkeratotic appearance. Patient is neurologically intact. However, I doubt with her likely underlying dementia she's the most accurate testing for protective sensation, vibratory, etc.

Infectious

Syphilitic (tabes dorsalis)

Reaction to foreign body - as above

Parasitic (unlikely unless recent travel history or endemic area)

Fungal

Bacterial/Tubercular

Underlying osteomyelitis or abscess Systemic

Uremia

Hemolytic disturbances such as sickle cell anemia

Nutritional deficiency

Cancer

Malignant melanoma

Squamous cell

Basal cell (unlikely location)

Met from other location

Underlying bone tumor with soft tissue invasion Factitious/self induced - you can't rule this out since there may be a dementia component

My next step would be:

1. Radiographs of the foot including lateral, calcaneal axial, lateral oblique views.
2. Blood testing: CBC w/ diff, lytes, BUN, Creatinine, prealbumin.
3. Incisional biopsy of the wound including both "normal" periwound tissue and wound tissue.
4. Deep tissue culture and sensitivity and gram stain for aerobic, anaerobic, fungal, and AFB. This would be performed after debridement to eliminate surface contamination.
5. Local wound care with wound gel and nonadherent dressing along with offweighting of area with reverse Ipos shoe or DH walker.
6. Would wait to start antibiotics at least until gram stain results available.
7. Attempt to counsel patient on dressing changes and hygeine. Patient would benefit from psych consult for dementia eval and support. May need home support/nursing.
8. Further treatment pending results of these tests.