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Hi all

I'm looking for some advice about a 69 year old male patient with a two year diagnosis of motor neurone disease. (He is still relatively mobile)

He presented to me two weeks ago with a grossly swollen great toe due to a chronically in-grown toenail. This toe is quite neuropathic hence the delay in seeking treatment. I'm hoping to try and resolve this conservatively, ie cutting the nail spike out, packing the sulci and changing his current narrow footwear, but have a feeling it will require surgical intervention.

Does anyone have any knowledge or experience of carrying out a nail avulsion with regard to use of local analgesia in MND? Are there likely to be any contraindications?

Any advice greatly appreciated.

Gill

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This reminds me about the old educator quote: See one do one, teach one. When I was in my first week in my residency I was walking through the operating room hallways and one of the anesthesiologists came up to me and asked me if I could show him how to do an ankle block for a sick diabetic patient who was undergoing a trans metatarsal amputation. The patient was too sick for general anesthesia. At that point I had seen a couple and performed one ankle block on a fellow student. Sure, I'll show you how to do an ankle block. Since the patient was also neuropathic I didn't have much to lose. The patient did not appear to feel any pain with some IV sedation. Was it a good block or profound neuropathy? Either way there wasn't any pain. I think your patient is in a similar situation. You can put the local anesthetic in, to make you feel better, but it may not make much difference.

The more important question you should be asking is will the patient heal after the procedure. What's the vascular status?

Regards,

Eric Fuller

Hi Gill:
Eric is correct, the vascular status is more important in this patient.
Motor Neuron Desease..most likely ALS, should not alter your treatment.
I&D or nail avulsion as usual and the patient should do well.
Steve

__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Adjunct Professor OCPM
Green Bay, Wisconsin, USA

Gill

What is the cause of the neuropathy? MND is a progressive disease of the motor system and as such the sensory pathways are unaffected. Agree with the comments re vascular status, but otherwise proceed as with any other patient, unless he is trialling any new medication that may interact with the local anaesthesia.

Regards

Mark

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www.mark-russell.net

"citing an indisposition due to special circumstances"

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Mark/Steve/Eric

Many thanks for your replies.

Happily his vascular status is fine and whilst he isn't as totally neuropathic as I first thought I'm grateful for the reassurance.

Gill

I too have performed nail avulsion on a motor neurone patient. The patient was still ambulatory and wanted to enjoy what time he had left of this without the nail being bothersome.

All passed uneventfully !!!