HELP stood on a sharp needle like object in the ball of the left foot.  The wound has healed but has created a hyperkeratotic leison which is painful. It is 5mm in dept and inch in lenth. What treatment can be used, as surgery is not recommended. Currently using silver nitrate, as all other remedies have failed.

They say it is a very thick callus.?

You likely have a subepidermal inclusion cyst.  Has the foot been x rayed to see if all visible traces of the needle are gone? Td updated? Surgical excision is usually neccessary but provides near instant pain relief if an inclusion cyst is infact the problem.  Occassioanlly with aggressive debridement you can access the white/tan fluid filled sacs under the skin.  They are fairly durable and can be pulled out with a forcept or hemostat.

Marc

 yes there has been an x-ray and scan.  nothing visible. Thanks.

Duanna,

I agree, sounds like an inclusion cyst.  Do you happen to have any photos that you can share with the community.  It my help....

Duanna, I like a local anesthetic block, given from the dorsum or an ankle postrior tibial block & debridement under Loupe magnification. I use #15 Swann-Morton blades d/t their superior sharpness compared to Bard Parkers, in my opinion. But there is a tradeoff to that sharpness, they dull more quickly. As mentioned above, if you do find that menbraneous layer it can often be sperated w/ a blunt curette. I pack those open for a few days and send the cyst out for a path evaluation. One of my favorite things is to get the 'trophy." It is usually a very rewarding procedure. Andy  

left:  picture is the lesion, blackness is the silver nitrate.

The lesion does not have any cyst like fluid it is just hard.skin (callus)

Duanna, Let's go back to why you say "as surgery s not recommended." To me a couple of things stand out. The -your?- foot looks swollen and red. Is there any pain with walking or palpation? Any pain or limitation of plantarflexion of any of the toes? Any increased temperature to the foot? (I use a non contact infrared thermometer w/ laser aiming to measure the differences in areas of the foot & ankle and from side to side. It is a very frequently used instrument in my office.) The lesion looks like it is much larger around than the entrance of the nail from the chair button. From your first description I was envisioning a linear lesion, this looks much more like a deep puncture wound. The silver nitrate is at the superficial level, maybe down a little, but not to the 1.7cm depth that the nail could have penetrated to. Also presuming the -your?- tetanus prophylaxis is up to date. This looks very much like a surgical foot to me, if not sooner, then probably later.

Andy

I concur with the esteemed Dr Levy. The foot is swollen, this is bad after a puncture wound.  The only reason not to open your foot and clean out where the needle was, would be a severe systemic medical condition or if you are going to cut the foot off anyway.  At this point, if you were in my office and surgery were ill advised due to medical history, you would need an MRI and/or Bone scan to rule out a bone infection and evaluate the extent of a deep abscess( if one is present).  If surgery cannot be done, IV antibiotics should be considered or Antibiotics with similar oral/IV bone penetration. Since your doctor cannot get any fluid out, no culture can be performed, so 2 or 3 antibiotics are needed to reduce the likelihood of resistance. 

You should be seen in someone's office right away. 

Good call on the picture request. 

Hi

The foot is very tender if walking flat footed.  It gets quite warm.  I am currently using a moon boot to keep pressure off that area.  The silver nitrate is no longer being used.  The surgen's say they will operate and take it out but they feel it is only going to form another problem.  So decided not too.  I also smoke so recovery will be longer.

They said that it may recover on it's own but it will take as long as I have had this lesion. 2yrs?

I have had no medicine and TP was not done after this incident happened.  As I waited 7 months before seeking help. Which was something I regret now. 

If I had been off my foot from the day this injury happened, would it have healed diferently?

Thanks to all of you

"If I had been off my foot from the day this injury happened, would it have healed differently?"  Water under the bridge, that is no longer relevant. You are also presenting a different history from an acute injury to a chronic one. Absolutely, the smoking will harm, delay & possibly prevent your healing properly. I agree w/ Dr. Garfield that you need additional diagnostic imaging ; an MRI with contrast and a bone scan, preferably a white blood cell labeled scan would be 2 important tools.

Here are the Reports:

Orthopaedic Surgeon:  Examination,  Has well aligned feet.  Walks with an antaigic gait.  Has no evidence of any forefoot swelling but there is a distinct area of hyperkeratotic  skin on the plantar aspects of the foot with a central punctunm. Movement of lesser toes is normal.

Ultrasound:  Plantar subcutaneous callus present in relation to 2nd metatarsal head of the left foot- sagittal measurement 12.5 x3mm.  The 2nd metatarsal head lies deep to this at a distance of 12mm.  Rest of subcutaneous tissue intact with no signs of foreign body.

Conclusion:  Local callus overlying the 2nd metatarsal head.  Less likely diagnosis would be that of a PLANTAR WART

Radiology:  Bony elements intact. Plantar calcaneal spur. No clear evidence of soft tissue foreign body.

So there it all is.. I am currently wearing off loading moon boots to prevent pressure on the injuired area.

So is this just a wart around the healed injuried site?  How is it going to go away?  The solutions that  they have used are not working.  They stopped applying them.  If I keep walking around on it and work the job I have which requires me standing 7 hrs a day 5 days a week.  Will this ever go away? 

What are the long term effects?

Thanks everyone for helping me.

Duanna

Any experienced podiatrist can tell if the lesion is a verruca or wart by gently trimming the callus tissue away and examining the tissue underneath.  You look for punctate bleeders( tiny areas of bleeding), discontinuity of the skin lines and a characteristic "cauliflower" appearance to the tissue.  An inclusion cyst, caused by embedding epidermal cells or other foreign body into the dermis or beneath it, also has a very characteristic appearance.  It has a central nidus.  Another item on the differential diagnosis list is a lesion called a Porokeratosis...which represents a clogged up sweat duct.

From the note that the orthopedic doctor wrote, I'm sorry to say that visit was a waste of time.  See the best podiatrist in your area, or even a dermatologist for evaluation and treatment of this lesion.  It is not a challenging case if it is identified and treated properly.

I used to wonder what all the excitement was about regarding porokeratosis until I got one.  It literally felt like stepping on a needle each step I took.  A porokeratosis can be caused by a scar or a callus.    A Plastizote insert is your best option if this is a porokeratosis caused by a scar.

On the one hand this looks like a submet 2 lesion- so I would use a 1/8 inch felt pad or even an orthotc with a mortons ext and met pad combo - and I would initially debride the area and use cantherone plus as if this were a wart to see if i can slough the skin off. If conservative care does not work - I would excise as others have recommened

Thank you,  I knew there was more too it.  

I just want it gone.  We have already used different techniques.  But unfortunately nothing is working.  I have even used a craft knife to scrape the top layer away, but it always grows back.

I will let you know what happens soon.

Listen to us. We have probably scared this man to death and frankly, that is a good thing. Sir, you need a thorough examination, one worth your money. Depending on how long ago the orthopedic examination was done, none of us know whether or not you have developed osteomyelitis from this puncture wound. The entry point would certainly make it a possibility though, I am sorry to say. The fact that your foot is reddened and swollen makes it a possibility.

Are you systemically ill?
Fever?
Chills?
If you are diabetic though, you might not mount a defense against an infection like that. Diabetics for instance don't always show a high "white count" in their blood work (Sorry, that is more for my colleagues here.)

You say surgery is not an option, which made us think that perhaps you are too ill to have surgery but your overall foot looks pretty healthy in terms of the rest of your skin. Did you mean that you can't be away from work long enough to recover from surgery or you can't afford to have surgery perhaps? Sorry to be so personal but we need the facts to give you the best answers.

A wart, or verruca, as Dr. Sherman discussed can be an extremely painful condition and that can be taken care of within a fairly short period of time by a good, well-trained podiatrist. After it is healed you will ask yourself why you ever suffered for so long without looking for an answer sooner.....if indeed that is what it is.

When you cut it away with a craft knife (which we must say - NEVER TRY AGAIN!!) did it have areas of pinpont bleeding? Does the lesion itself look like it has little black dots speckled throughout its surface?

Does it hurt more when you step down on it or when you pinch it side to side? This too will tell us something.

While we can try to help you via the internet, nothing replaces an appointment with a good podiatric physician who can assess you face to face or face to foot!
Good luck to you and please do it soon.

Hi

Thank you for your concern.  I am a 46 year old female.  The punctured area gets very sore when standing/ walking too long.  The wound is not a verruca and has no black spots, fluid, blood or anything else unusal. It looks like a callus which goes deep inside where the wound is/ was.

 I have had no chills and  I am not a Diabetic.  The podiatry specialist has worked on my foot but the callus like head keeps forming back and I still have pain when walking it's like a sharp pointy  hard thing pushing down inside the soft part of the foot.  Maybe the puncture has form into something?

I am off work as we have a system here in New Zealand that if you get injuired you apply for ACC(accident compensation) government funded, and with a medical certifcate from your doctor you can be put off work for recovery. And be paid for loss of earnings while off. They also pay for all your specialist visits and treatments and even surgery. 

The reason that the Orthopedic Surgeon has decided to not operate, he feels that it may cause another problem.

It also hurts when you pinch around it. It hurts right in the middle where the punctured entrance is.

I am now gone back to using salicyic acid again,  been using a week. silver nitrate was doing nothing.

I must say since using the moon boot it's not throbbing or hurting as much. As I'm not walking on it.

I will put up another picture for you.

Thanks

Duanna