Addressing A Unique Skin Ulceration In A Patient With Neuromuscular Disease

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Author(s): 
Eric Feit, DPM, FACFAS, and Armin Feradouni, DPM

These authors discuss the diagnostic workup and eventual surgical treatment to resolve a chronic ulcer in a patient with a history of polio and spina bifida.

A 32-year-old male presented to our office with a chief complaint of a non-healing skin ulceration on the dorsum of the left foot (see figures 1,2,3). The patient had a history of polio and spina bifida, and ambulates with below-knee custom ankle foot orthoses and crutches. He had been walking comfortably for years and did not have a prior skin ulceration on this foot. He denied trauma and his brace did not apply pressure in the area. The patient wore extra-depth shoes and they fit well.

   He had multiple surgeries as a child. These surgeries included an Achilles tendon lengthening, multiple tendon transfers and a subtalar joint arthrodesis. The patient says the shape of his left foot has changed slightly over the past six months. The hallux is flaccid with no muscle function and as a result, he sometimes trips when walking.

   The physical exam revealed a dorsal skin ulceration over the first metatarsal. The ulceration was 15 x 18 mm in size and 3 mm in depth. There was no undermining. There was yellow serous drainage without an odor. Initially, the patient had erythema at the periphery of the wound, which resolved after one week with oral amoxicillin/clavulanic acid (Augmentin, GlaxoSmithKline). The first metatarsal was elevated relative to the second metatarsal and was in spasm. There was also spasm and tightness of the anterior tibial tendon, causing mild inversion. The left hallux was dysfunctional and was in a “dropped” position relative to the first metatarsal.

   Manual muscle testing of the left foot and leg revealed severe weakness of the extensor tendons to the foot (1/5) and hallux (0/5), and testing of the plantar flexors of the foot revealed mild but decreased muscle strength (2/5). The posterior tibial and anterior tibial tendon had minimal muscle strength (1/5) and the peroneal tendons were also weak (1/5). The quadriceps and hamstring muscles were more functional but still weak (3/5). The ankle joint dorsiflexion was 0 degrees with the knee flexed and extended. The tendon was very thin due to previous surgery during the patient’s childhood. The neurologic exam revealed absent sharp/dull sensation and light touch to the foot both dorsally and plantarly. The vascular exam was within normal limits with palpable and normal dorsalis pedis and posterior tibialis arteries (+3/4).

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