Tailor's Bunion

Tailor's bunion is as an acquired lesion that causes chronic pain and swelling over the outer aspect of the distal foot. It is also known as a bunionette and is characterized by a painful prominence on the outer aspect of the foot in the area of the fifth metatarsal head.

These types of lesions were often seen on tailors with a cross-legged sitting posture. The posture resulted in pressure being placed on the lateral side of the foot.

Causes

Extrinsic causes - Commonly chronic

• Tailors' posture
• Footwear

Intrinsic causes

Structural Abnormalities

• Lateral bowing of the metatarsal shaft
• Enlargement of the metatarsal head
• Congenital splayfoot

Presentation

• Symptoms - Painful keratoses on the outer, bottom, or top aspect of the metatarsal head.

Imaging Studies

• Weight-bearing x rays of both feet
• Vascular studies are important with patients who have questionable circulation

Treatment

Conservative

• Padding
• Shoe modification
• Orthotic devices
• Anti-inflammatory medications
• Corticosteroid injections

Surgical Treatment

• Can be treated with simple removal of osseous bump when there is no evidence of anglular deformity
• With an angular deformity or a deviation in the bone is present an osteotomy (cut in the bone) is made and held together with a screw. The level of bone cut varies with the level of the deformity.

Possible Complications

• Malunion- Incomplete union or union in a faulty position
• Nonunion- A nonunion occurs when a broken bone does not heal
• Nerve Injury
• Joint pain and stiffness
• Symptomatic hardware
• Infection
• Recurrence

Diabetic Education

General Education for Diabetics:

Avoid any at home care for nails and calluses

Avoid constrictive bandages

Avoid open toed or opened back shoes

Be careful with adhesives and tape on the diabetic insensate foot

Buy shoes at the end of the day when the feet are the largest

Check the bath temperature before submerging the feet

Diabetics with impaired vision need someone to inspect there feet daily

Do not use chemical substances for removing corns or calluses

Dry the feet and between the toes thoroughly after showers

Inspect the feet and toes daily for any lesions

Inspect the shoes for objects before placing on feet

Never walk barefooted

Professional nail care at a podiatry office with regular visits

Protect the feet from sunburn

The use of a high toe box to accommodate hammertoes

The use of an insert to accommodate any lesions

The use of shoes with a wide toe box with extra depth

The use of water based lotion daily without moistening between the toes

Wear a shoe with an appropriate fit to avoid friction which can cause blisters

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Psoriasis

Psoriasis is a common, chronic, relapsing, inflammatory skin disorder. Psoriasis has a genetic basis and can affect the skin the nails and also joints.

Psoriasis has a tendency to wax and wane.

Flares can be related to systemic, environmental factors, or infection.





Psoriasis most commonly manifests itself on the skin of the elbows, knees, scalp, and lumbosacral areas.



Most psoriatic nail disease occurs in people with clinically evident psoriasis.


Psoriatic arthritis is a chronic inflammatory arthritis that is commonly associated with psoriasis.



Frequency

Approximately 2-3% of people are affected by psoriasis

At least 5% of patients with psoriasis develop psoriatic arthritis

Sex

Psoriasis is slightly more common in women than in men


Symptoms of Psoriasis

The surface of psoriatic lesions often has a layer of dead skin cells that appear as silver scales.

Erythematous(Red) scaly area which can have a sudden onset.

Scaling plaques that itch.

Lesions may be vesicular.

Joint Pain.



Joint Findings

Sausage Digits

Enthesopathy- An inflammation of the insertion points of tendon into bone.

Tendonitis


Nail Findings

Oil drop - a translucent, yellow-red discoloration in the nail bed resembling a drop of oil beneath the nail plate.


Pitting- Pitting is a result of the loss of cells from the surface of the nail plate.


Beau lines- These lines are transverse lines in the nails


Leukonychia- Leukonychia is areas of white nail plate.


Onycholysis Onycholysis is a separation of the nail plate from its attachment to the nail bed.



Causes


Psoriatic lesions are caused by an increase in the skin cells turnover rate.

Genetic factors- Approximately 40% of patients with psoriasis or psoriatic arthritis have first-degree relatives who are affected.

Psoriatic nail disease may be due to a combination of genetic, environmental, and immune factors.



Differentials

• Seborrheic dermatitis
• Onychomycosis
• Squamous cell carcinoma
• Nummular eczema
• Lichen planus
• Lichen simplex chronicus
• Pustular eruptions

Arthritic Differentials

• Gout
• Osteoarthritis
• Rheumatoid arthritis
• Septic arthritis

Work Up


Radiographs of affected joints can be help differentiate the type of arthritis.

Psoriatic arthritis- The diagnosis is based primarily on clinical and radiographic findings.

Nail biopsy- A nail biopsy may be obtained to confirm the diagnosis of nail psoriasis



Laboratory studies

Rheumatoid factor (RF)- negative

Erythrocyte sedimentation rate (ESR)- usually normal

Uric acid level- May be elevated in psoriasis





Treatment

Skin Lesions

Topical corticosteroids- Used to reduce plaque formation.


Coal tar- Coal tar is an inexpensive treatment that is available over the counter in shampoos or lotions for use in widespread areas of involvement..

Keratolytic agents- Used to remove scale, to smooth the skin, and to treat hyperkeratosis


Psoriatic arthritis

Nonsteroidal anti-inflammatory drugs- (NSAIDs)

Disease-modifying antirheumatic drugs (DMARDs)

Anti–tumor necrosis factor (TNF)-alpha medications.

Nails
Avulsion therapy -can be used as an alternative therapy for psoriatic nail disease.

Gout

Gout is a common disorder of uric acid metabolism. It is a medical condition that usually presents with recurrent attacks of acute inflammatory arthritis. Gout is caused by cellular reaction to uric acid and can lead to deposits of monosodium urate crystals in soft tissues and joints.



Types

Primary gout - May occur alone. Accounts for about 90% of cases of the disease.

Secondary gout- May be associated with other medical conditions or medications. Accounts for about 10% of cases of the disease.


Frequency
Approximately 1% of the general population have gout.

Sex
Predominance- 90% male


Symptoms

Gout is associated with considerable pain.

Acute episodes of gout may incapacitate a patient.

Involved joints typically have the following symptoms: swelling, warmth, erythema, and tenderness.

The first metatarsal phalangeal joint is most commonly affected, however other joints can be involved such as the ankle or the knee.


A tophus deposit may develop in the ear.


Causes

Conditions that may cause acute changes in the level of uric acid and may precipitate a gout attack:

• Hyperuricemia
• End-stage renal disease
• Alcohol ingestion
• Disorders that cause high cell turnover with release of purines
• Over consumption of foods high in purines
• Underexcretion of uric acid - renal insufficiency

Long Term Effects

Untreated chronic tophaceous gout can lead to severe joint destruction.

Deposition of uric acid crystal in the kidneys may produce renal failure or obstruction.


Differential Diagnosis

Cellulitis- A severe inflammation of dermal and subcutaneous layers of the skin.

Gonococcal Arthritis- Is caused by infection with Neisseria gonorrhoeae.

Calcium Pyrophosphate Deposition Disease- Is a type of arthritis caused by the deposition of calcium pyrophosphate crystals.

Rheumatoid Arthritis- Is a chronic systemic inflammatory disease that affects the peripheral joints.

Psoriatic Arthritis- Is a chronic inflammatory arthritis that is commonly associated with psoriasis.


Laboratory Studies

Synovial fluid- The physician may aspirate the involved joint to rule out an infectious arthritis and to confirm a diagnosis of gout.

Serum uric acid.

Uric acid in 24-hour urine sample.


Imaging

Routine radiographs reveal punched-out erosions or lytic areas with overhanging edges. These finding are not acute.



Treatment

Acute gout

• Indomethacin- is the traditional Nonsteroidal anti-inflammatory drug (NSAID) of choice for acute gout.
• Colchicine.
• Corticosteroids- May be indicated in those patients who do not tolerate NSAID or Colchicine.

Chronic gout

• Probenecid- For patients who are hypoexcreters of uric acid.
• Allopurinol- For patients who are over producers of uric acid. Allopurinol reduces the generation of uric acid in the body.
• Uloric- Prevents uric acid production and lowers elevated serum uric acid levels.

Diet

Patients with gout should avoid beer and hard liquor. These elevate levels of uric acid and may precipitate attacks of gout.

High purine foods should be consumed in moderation:

• Kidney
• Liver
• Meats
• Shellfish