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I have a patient with a very painful lateral heel fissure.

History of motor vehicle accident 2007 with subsequent right ankle fracture. Underwent ankle fusion. Now walks on lateral border of heel. Has now developed a lateral heel fissure which heels but then "splits". Has had fissure become infected with last infection 5/7 ago with redness spreading up leg, chills, fever, swelling in groin. Placed on antibiotics & majority of symptoms have resolved.

Heel has significant callus over lateral border which I have debrided & around the fissure as much as possible. He wears a Rockport shoe with a lateral flare. He also wears an approximately 10mm red PPT insole to provide increased cushioning.

Does anyone have any advice regarding other options to deal with this fissure. It will close over with debridement & dressings. That is not a problem. But will re-split fairly quickly once callus builds up. I will be debriding more frequently but are there other suggestions on either more appropriate footwear, footwear modifications, soft insole etc? He has no ability to evert his foot so I am thinking he needs much more cushioning. I've attached (hopefully) below some pictures. They were hurriedly taken & not perfect.

Attached Images

	Patient1.JPG (30.0 KB, 208 views)
	Patient3.JPG (28.8 KB, 205 views)
	Patient4.JPG (31.9 KB, 205 views)
	Patient2.JPG (37.2 KB, 203 views)

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Hi Markleigh, great photos, does the fissure split with the dryness as well as the build up? Tulis type heel cups can be a great way to keep the skin from drying out, has at times worked when nothing else has. Have had some success with the H/k build up too. Have had clients who use this under socks and apply moisturiser in it, need to mindful of slippage, some have worn after hours, some during biz type hours.
There is always super glue. or the modern equivalent?
Cheers

__________________
Heather J Bassett
137 Wheatsheaf Road
GLENROY VICTORIA 3046
AUSTRALIA
03 9306 8557

Thanks Heather. Had thought of Tulis. It splits because of the high forces in the area which I guess is directly connected to the callus buildup.

I have heard of superglue or the medical equivalent being used for splits. Is it an actual medically recommended treatment & what is the medical form of superglue? Is it recommended for those who have had infections arising from the fissure?

Lastly, this gentleman has some fairly solid hardward in his ankle (screws, plates etc). While I've seen localised infections in fissures, I haven't seen/heard of an infection occuring so rapidly & spreading so far proximally up a leg. Could this be related to the hardware in any way rather than just the fissure? As this is the 3rd or 4th time of infection, I'm thinking maybe an x-ray/further scans might be worth considering.

Hi 2 weeks ago I sent a client back to her Gp re her wrist, advising that the swelling, pain and surrounding redness was not what I would expect if this was post surgery of the foot. I rang and organised an appointment with GP immediately following completion of our appointment.
I admitted in my letter that the wrist was not my area of expertise (GP been telling client all was fine for a several of weeks at this stage.)
After my referral and my letter pt was sent back to hospital that day, luckily surgeon was on staff, operated a couple of hours later. Several days later, new wrist, healthier client very HAPPY client, no longer in pain.
So my recommendation would be to go with your gut! If it is outside the square then get it checked out with further testing or referral back to surgeon.
Problem is can not glue once it is infected.
Cheers

__________________
Heather J Bassett
137 Wheatsheaf Road
GLENROY VICTORIA 3046
AUSTRALIA
03 9306 8557

HI Mark
Great pics of a knotty problem.
IF the fat pad pivots on what is the knife edge of the heel seat, there would be increased shear. A silicon heel protector called a Gelbo may help. Would the heel be affected by balancing the forefoot with a "reverse mortons", 2-5 ?
Regards Laurie Foley
Chief Pod Fremantle Hospital

Some good thoughts Laurie. I have just ordered him a silicone heel cup to trial. I will look up a "Gelbo" - never heard of it. Will also consider Reverse Mortons - he has no rearfoot movement at all - fixed in inverted position but will check how much lateral forefoot elevation he has (if any) available. Thanks.

Hello Mark,
Silicone heel cup - perfect The 'superglue' I use which usually works a treat is Tinc Benz dripped into the fissure followed by a piece of 5cm wide Haplaband stretched around the heel ie under slight tension. This dressing would have to be renewed but it isn't exactly rocket science so can be performed by a relative etc. As an ongoing treatment once the fissure has healed regular application of a good heel balm with a very high urea content massaged in as strongly and carefully as is possible in this particular case could be an effective preventative measure.
Regards
Jo

These fissurwes can be a problem but I have had success with Splitz cream (podiacare ltd) and then a prescription orthotic with a between a 3 and 4 degree posting.

Hope it helps.