Hidden depthsunsuspected soft tissue infection complicating apparently superficial heel ulceration under callus

A 56-year-old man with type 2 diabetes of 12 years' duration and peripheral neuropathy trod on a nail while walking barefoot. The wound healed after 6 days, but the heel developed a callus which became painful after 2 weeks so he sought advice from the diabetic foot service. The callus was debrided and the underlying skin appeared to show superficial ulceration only (Fig. 5.10a). However, when the heel was palpated the patient complained of pain, and careful inspection revealed a deep sinus from which a bead of pus could be expressed (Fig. 5.10b). He was admitted for intravenous antibiotics, a surgical opinion was sought and he underwent extensive operative debridement of infected sloughy tissue the same day (Fig. 5.10c). The large residual defect healed after 7 months (Fig. 5.10d).

Keypoints

• Puncture wounds can lead to deep infections

• Pain on palpation in the ulcerated neuropathic foot is often a symptom of severe underlying infection

• Careful palpation may express pus and reveal a deep sinus

• Puncture wounds may be complicated by cellulitis and lead to this presentation. Bacteria are inoculated at the base of the puncture wound and then track back towards the surface of the skin, with infection eventually manifesting itself as a cellulitis and extensive deep soft tissue infection.

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