When A Patient Has A Post-Op Bullous Reaction
A 39-year-old female presented to my office with a chief complaint of pain surrounding both great toe joints. She had symptoms for five to six years. Prior treatment measures included wearing wider shoes and bunion pads. Her main area of pain was on the medial bony prominence at the great toe joint.
Her past medical history was remarkable for depression. Daily medications included sertraline (Zoloft, Pfizer), fish oil, vitamin B12 and vitamin D. Allergies included an allergy to penicillin, which caused a rash but not anaphylaxis. Past surgical history included two Caesarean sections and excision of keloids. The patient was married, unemployed, a non-smoker and a mild drinker of alcohol.
The podiatric exam revealed strong pedal pulses of 2/4 for the dorsalis pedis and posterior tibial arteries bilaterally. The capillary refill was less than three seconds to the toes. Her skin was warm and pink. The neurologic exam revealed symmetric deep tendon reflexes and epicritic sensation was intact to the level of the toes. There was no clonus or Babinski reflex.
The dermatologic exam revealed skin temperature, texture and turgor within normal limits. There was no evidence of rash, edema, varicosities or a break in the integument. Her toenails were healthy. The orthopedic exam revealed symmetric, pain-free range of motion of the ankle and hindfoot. Gross visualization of her feet revealed mild to moderate bunion deformities with lateral deviation of the great toes. The range of the motion of the great toe joints was not painful. The dorsomedial eminence of the great toe joint was painful to palpate.
Radiographs of her feet revealed a moderate underlying metatarsus adductus with mild to moderate bunion deformity. No acute fracture was visible. No underlying arthropathy was present.
The patient elected to have surgery to address the chronic pain and deformity of her feet. She wanted to have surgery on the right foot first. Abnormal preoperative labs were remarkable for a mean corpuscular volume of 76.3 (normal values 81.0 FL-97.4 FL), a mean corpuscular hemoglobin of 24.8 (normal values 37.0 PG- 34.0 PG) and a red blood cell distribution width of 16.2 (normal values 11.7%-14.4%). Her remaining complete blood counts and chemistry profile were normal.
I performed a traditional Austin bunionectomy with single screw fixation in a standard fashion. Due to the patient’s history of keloids, I used a minimal reactive suture. I closed the skin with a 5-0 Prolene suture in a running intradermal stitch, using Mastisol (Eloquest Healthcare) and Steri-Strips (3M) to reinforce the skin. Her surgery progressed without any technical difficulty or complications.
The patient followed up in one week for her first postoperative appointment. She had been in moderate pain and described some itching on her foot. She self treated with diphenhydramine (Benadryl, McNeil Consumer Healthcare) and that did help. Clinically, her foot was very swollen and red. I was concerned about infection due to the bright red appearance of her dorsal foot. I cleansed the foot, wrapped it in an elastic compression bandage and instructed her to continue to elevate and ice the foot. She wore a pneumatic fracture boot for weightbearing as tolerated. I gave her a prescription for clindamycin (Cleocin, Pfizer) 300 mg #21, i PO TID. I advised her to return to the office in two weeks.
I received a phone call from the patient two days after her initial postoperative visit. She noted that she was developing a blister on the top of her foot and having more itching and pain. I instructed her to return to the office the following day for evaluation.
A large bulla was present in the interspace between the big toe and the second toe. I removed her Steri-Strips to inspect the rest of the surgical wound and found multiple small vesicles in the region of the Steri-Strips and to the periphery of the incision line. There was no evidence of purulence. I drained the bulla, which was flaccid and contained a serosanguineous fluid, but I left the roof of the blister intact. The area of erythema was localized to the surgical site. No ascending lymphangitis was present.