Tag Archives: Bunion

Bunions

Definition:
A bunion is an enlargement of bone or tissue around the joint at the base of the big toe (metatarsophalangeal joint).The big toe (hallux) may turn in toward the second toe (angulation), and the tissues surrounding the joint may be swollen and tender.

CLICK & SEE THE PICTURES

The term is used to refer to the pathological bump on the side of the great toe joint. The bump is partly due to the swollen bursal sac and/or an osseous (bony) anomaly on the mesophalangeal joint (where the first metatarsal bone and hallux meet). The larger part of the bump is a normal part of the head of first metatarsal bone that has tilted sideways to stick out at its top.

Although they’re more common in older people, they can begin at any age, and even children can develop them. A similar bump, but on the outer edge of the foot at the base of the smallest toe, is known as a bunionette.

The term “hallux valgus” or “hallux abducto-valgus” are the most commonly used medical terms associated with a bunion anomaly, where “hallux” refers to the great toe, “valgus” refers to the abnormal angulation of the great toe commonly associated with bunion anomalies, and “abductus/-o” refers to the abnormal drifting or inward leaning of the great toe towards the second toe, which is also commonly associated with bunions. It is important to state that “hallux abducto refers to the motion the great toe moves away from the body’s midline. Deformities of the lower extremity are usually named in accordance to the body’s midline, or the line bisecting the body longitudinally into two halves.

Bunions most commonly affect women. Some studies report that bunions occur nearly 10 times more frequently in women then men.

Symptoms:
Bunions may or may not cause symptoms. A frequent symptom is pain in the involved area when walking or wearing shoes that is relieved by resting. A bunion causes enlargement of the base of the big toe and is usually associated with positioning of the big toe toward the smaller toes. This leads to intermittent or chronic pain at the base of the big toe.

Bunions that cause marked pain are often associated with swelling of the soft tissues, redness, and local tenderness.

The symptoms of bunions include irritated skin around the bunion, pain when walking, joint redness and pain, and possible shift of the big toe toward the other toes. Blisters may form more easily around the site of the bunion as well.

Having bunions can also make it harder to find shoes that fit properly; bunions may force a person to have to buy a larger size shoe to accommodate the width the bunion creates. When bunion deformity becomes severe enough, the foot can hurt in different places even without the constriction of shoes because it then becomes a mechanical function problem of the forefoot.

Risk Factors & Causes:
It is found  that tight-fitting shoes, especially high-heel and narrow-toed, might increase the risk for bunion formation.
Bunions are reported to be more prevalent in people who wear shoes than in barefoot people. There also seem to be inherited (genetic) factors that predispose to the development of bunions, especially when they occur in younger individuals.

Other risk factors for the development of bunions include congenital (present from birth) abnormal formation of the bones of the foot, nerve conditions that affect the foot, rheumatoid arthritis, and injury to the foot. Bunions are common in ballet dancers.

Bunions are mostly genetic and consist of certain tendons, ligaments, and supportive structures of the first metatarsal that are positioned differently. This bio-mechanical anomaly may be caused by a variety of conditions intrinsic to the structure of the foot – such as flat feet, excessive flexibility of ligaments, abnormal bone structure, and certain neurological conditions. These factors are often considered genetic. Although some experts are convinced that poor-fitting footwear is the main cause of bunion formation, other sources concede only that footwear exacerbates the problem caused by the original genetic structure.

Bunions are commonly associated with a deviated position of the big toe toward the second toe, and the deviation in the angle between the first and second metatarsal bones of the foot. The small sesamoid bones found beneath the first metatarsal (which help the flexor tendon bend the big toe downwards) may also become deviated over time as the first metatarsal bone drifts away from its normal position. Arthritis of the big toe joint, diminished and/or altered range of motion, and discomfort with pressure applied to the bump or with motion of the joint, may all accompany bunion development.

Diagnosis:
A doctor can usually diagnose a bunion by looking at it. A foot x-ray can show an abnormal angle between the big toe and the foot and, in some cases, arthritis.

The doctor considers a bunion when noting the symptoms described above. The anatomy of the foot is assessed during the examination. Radiographs (x-ray films) of the foot can be helpful to determine the integrity of the joints of the foot and to screen for underlying conditions, such as arthritis or gout. X-ray films are an excellent method of calculating the alignment of the toes.

Treatment:
Bunions may be treated conservatively with changes in shoe gear, different orthotics (accommodative padding and shielding), rest, ice, and medications. These sorts of treatments address symptoms more than they correct the actual deformity. Surgery, by an orthopedic surgeon or a podiatrist, may be necessary if discomfort is severe enough or when correction of the deformity is desired.

Orthotics are splints, regulators while conservative measures include various footwear like gelled toe spacers, bunion / toes separators, bunion regulators, bunion splints, and bunion cushions.

Surgery:
Procedures are designed and chosen to correct a variety of pathologies that may be associated with the bunion. For instance, procedures may address some combination of:

*removing the abnormal bony enlargement of the first metatarsal,
*realigning the first metatarsal bone relative to the adjacent metatarsal bone,
*straightening the great toe relative to the first metatarsal and adjacent toes,
*realigning the cartilagenous surfaces of the great toe joint,
*addressing arthritic changes associated with the great toe joint,
*repositioning the sesamoid bones beneath the first metatarsal bone,
*shortening, lengthening, raising, or lowering the first metatarsal bone, and
*correcting any abnormal bowing or misalignment within the great toe.

At present there are many different bunion surgeries for different effects. Ultimately, surgery should always have function of the foot in mind besides its look. Can the proposed surgery help resolve the pain and callus under the middle metatarsal heads? Can one return to sports? Can the foot enjoy fashionable or high heel shoes like normal feet without undue discomfort? Does the proposed surgery prevent recurrence with any specific built-in mechanism? These are very reasonable challenges for any truly functional bunion surgeries but may not be so for esthetic bunion surgeries.

The age, health, lifestyle, and activity level of the patient may also play a role in the choice of procedure.

Bunion surgery can be performed under local, spinal, or general anesthetic. The trend has moved strongly toward using the less invasive local anesthesia over the years. A patient can expect a 6- to 8-week recovery period during which crutches are usually required for aid in mobility. An orthopedic cast is much less common today as newer, more stable procedures and better forms of fixation (stabilizing the bone with screws and other hardware) are used.

Prognosis:
The prognosis depends on your age and activities, and the severity of the bunion. Teenagers may have more trouble treating a bunion than adults. Many adults do well by caring for the bunion when it first starts to develop, and wearing different shoes. Surgery reduces the pain in many, but not all, people with bunions.

Possible Complications:

*Chronic foot pain
*Foot deformity
*Stiff foot
*Hallux varus (occurs with surgical over-correction, where the toe points away from the second toe

Disclaimer: This information is not meant to be a substitute for professional medical advise or help. It is always best to consult with a Physician about serious health concerns. This information is in no way intended to diagnose or prescribe remedies.This is purely for educational purpose.

Resources:
http://www.medicinenet.com/bunions/page2.htm
http://www.nlm.nih.gov/medlineplus/ency/article/001231.htm
http://en.wikipedia.org/wiki/Bunion
http://www.bbc.co.uk/health/physical_health/conditions/bunions.shtml

http://www.consumerreports.org/health/conditions-and-treatments/bunions/what-is-it.htm

http://www.cafai.com/bunions.html

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Ingrown Toenail

An ingrown toenail is a toenail that has grown into the skin instead of over it. This usually happens to the big toe, but it can also happen to other toes. An ingrown toenail can get infected. It may be painful, red, and swollen, and it may drain pus. See an illustration of an ingrown toenail….CLICK & SEE THE PICTURES
It occurs when a nail grows into the flesh at the side of the nail. This usually affects the toes, particularly the big toe. People with curved or thick nails are most likely to develop a problem with ingrown nails, although ingrown nails can affect anyone.

Anyone can get an ingrown toenail, but adults get them more than children do. People who have curved or thick nails are more likely to get an ingrown toenail. This is more common in older adults.

Causes:

An ingrown toenail can have a number of different causes. Cutting your toenail too short or rounding the edge of the nail can cause it to grow into the skin. Wearing shoes or socks that don’t fit well can also cause an ingrown toenail. If your shoes are too tight, they might press the nail into the toe and cause it to grow into the skin.

You can get an ingrown toenail if you hurt your toe, such as stubbing it. This can cause the nail to grow inward. Repeating an activity that injuries the nail, such as kicking a soccer ball, can also cause an ingrown nail.

Ingrown toenails result when the nail grows into the flesh of your toe, often the big toe. Common causes include:

  • Wearing shoes that crowd your toenails
  • Cutting your toenails too short or not straight across
  • Injury to your toenail
  • Unusually curved toenails
  • Thickening of your toenails

An ingrown toenail can result from curved toenails, poorly fitting shoes, toenails that are trimmed improperly, or a toe injury. The skin around the toenail may become red and infected. The great toe is usually affected, but any toenail can become ingrown.

The condition may become serious in people with diabetes.

Symptoms:

Signs and symptoms of an ingrown toenail include:

*Pain and tenderness in your toe along one or both sides of the nail
*Redness around your toenail
*Swelling of your toe around the nail
*Infection of the tissue around your toenail

Risk factors:

Anyone can develop an ingrown toenail. But you may be more prone to ingrown toenails if you have toenails that curve down.

Ingrown toenails are also more common in older adults, because nails tend to thicken with age. This thickening or change of the curvature of your nails can cause ingrown toenails.

Complications:

Left untreated or undetected, an ingrown toenail can infect the underlying bone and lead to a serious bone infection.

Complications can be especially severe if you have diabetes because the circulation and nerve supply to your feet can be impaired. Therefore, any relatively minor injury to your foot — cut, scrape, corn, callus or ingrown toenail — can lead to a more serious complication. In rare cases, an ingrown toenail can result in a difficult-to-heal open sore (foot ulcer), which could eventually require surgery. Foot ulcers left untreated may become infected and eventually even gangrenous. Rarely, amputation is the only treatment option.

Exams and Tests:
A doctor’s examination of the foot is sufficient to diagnose an ingrown toenail.

Treatment:

To treat an ingrown nail at home:

  1. Soak the foot in warm water.
  2. Use a nail file to separate the nail from the inflamed skin.
  3. Place a small piece of cotton under the nail. Wet the cotton with water or antiseptic.

Repeat those steps, several times a day if necessary, until the nail begins to grow out and the pain goes away. Also, trim the toenail and apply over-the-counter antibiotics. If this does not work and the ingrown nail gets worse, see a foot specialist (podiatrist) or skin specialist (dermatologist).

If steps you take at home don’t help, your doctor can treat an ingrown toenail by trimming or removing the ingrown portion of your nail to help relieve pain. Before this procedure, your doctor numbs your toe by injecting it with an anesthetic. After the procedure, you may need to rest your foot and soak it in warm water. Your doctor may also recommend using topical or oral antibiotics for ingrown toenail treatment, especially if the toe is infected or at risk of becoming infected.

For a recurrent ingrown toenail, your primary doctor or foot doctor may suggest removing a portion of your toenail along with the underlying tissue (nail bed) to prevent that part of your nail from growing back. This procedure can be done with a chemical, a laser or other methods.

Prognosis:
Treatment will generally control the infection and relieve pain. However, the condition is likely to return if measures to prevent it are not taken. Good foot care is important to prevent recurrence.

Prevention :

To prevent an ingrown toenail:

  • Wear shoes that fit properly.
  • Trim toenails straight across the top and not too short.
  • Keep the feet clean and dry.
  • People with diabetes should have routine foot exams and nail care.

Disclaimer: This information is not meant to be a substitute for professional medical advise or help. It is always best to consult with a Physician about serious health concerns. This information is in no way intended to diagnose or prescribe remedies.This is purely for educational purpose.

Resources:

http://www.revolutionhealth.com/articles/ingrown-nail/tp12748
http://www.mayoclinic.com/health/ingrown-toenails/DS00111/DSECTION=4
http://www.nlm.nih.gov/medlineplus/ency/article/001237.htm

Ingrown Nails

Onychocryptosis, commonly known as ingrown nails (unguis incarnatus) or ingrowing nails, is a common form of nail disease. It is a painful condition in which the nail grows or cuts into one or both sides of the nail bed. While ingrown nails can occur in both the nails of the hand and feet, they occur most commonly with toenails.

Ingrown nail

Causes
Causes include:

  1. poor maintenance, like cutting the nail too short, rounded off at the tip or peeled off at the edges (versus being cut straight across), is likely to cause ingrowth;
  2. ill-fitting shoes, like those that are too narrow or too short, can cause bunching of the toes in the developmental stages of the foot (frequently in the under 21s), causing the nail to curl and dig into the skin;
  3. trauma to the nail plate or toe, such as can occur by stubbing the toenail, dropping things on the toe and ‘going through the end of your shoes’ in sports, can cause the flesh to become injured and the nail to grow irregularly and press into the flesh;
  4. predisposition, like abnormally shaped nail beds, nail deformities caused by diseases, and a genetic susceptibility to nail problems can mean a tendency to ingrowth.

Symptoms:
Symptoms of an ingrown nail include pain along the margins of the nail (caused by hypergranulation that occurs around the aforementioned region), worsening of pain when wearing shoes or other tight articles, and sensitivity to pressure of any kind, even that of light bedding. Bumping of an affected toe with objects can produce sharp, even excruciating, pain as the tissue is punctured further by the ingrown nail. By the very nature of the condition, ingrown nails become easily infected unless special care is taken to treat the condition early on and keep the area as clean as possible. Signs of infection include redness and swelling of the area around the nail, drainage of pus and watery discharge tinged with blood. The main symptom is swelling at the base of the nail on whichever side (if not both sides) the ingrowing nail is forming.
Chronically ingrown toenail (that twice had failed wedge resections on both sides)
Treatment:

Treatment of ingrown nails ranges from soaking the afflicted area to surgery. The appropriate method is dictated by the severity of the condition. In nearly all cases, drainage of blood or watery discharge should mean a trip to the doctor, usually a podiatrist, a specialist trained explicitly to treat these conditions. Most practitioners agree that trying to outwait the condition is nearly always fruitless, as well as agonizing.
Alternative Medication:   Because of the possibility of serious complications, a physician should be consulted for treatment of severe and/or infected ingrown nails. Alternative treatments for treating ingrown nail include:

Ayurveda. Ayurvedic principles state that persons whose constitutions are dominated by vata and kapha have stronger nails and are prone to ingrown nails. Ingrown nails are treated with warm water soaks followed by application of a solution of equal parts tea tree and neem oils under the nails.

Herbal therapy. When an ingrown nail is forming, the toe should be soaked for 15-30 minutes in five drops each of hypericum and calendula tinctures diluted in 1/2 pint of warm water. Afterward, the toe should be wrapped in linen, placing it between the fold and the nail.

Homeopathy. Preparations of Hepar sulph or Silica in 6c potency may be taken every 12 hours for two weeks, to reduce the inflammation around the nail.

Hydrotherapy. To treat ingrown nail, the patient should soak the foot in hot, soapy water for 20 minutes, trim the nail square, wrap the toe in a hot compress, and cover it with a dry cloth overnight. In the morning, the patient should trim the nail into a U shape and place a bit of cotton between the nail and the fold. The cotton should be kept in place until the nail grows out.

Massage. If an ingrown nail is developing the patient should push the skin away from the nail. Repeated massage of the overgrown lateral nail folds can reduce pain and separate the fold away from the nail.

Home care:
In mild cases (not including the severe cases in the photos above), doctors recommend daily soaking of the afflicted digit in a mixture of warm water and Epsom salts and applying an over-the-counter antiseptic. This might allow the nail to grow out so it may be trimmed properly and the flesh to heal. A simple yet extremely painful procedure for mild ingrowth (i.e., where infection is absent) requires small scissors to trim the nail completely along the nail margin down to the lateral base. This hopefully allows the embedded piece of nail to be pushed back and out from the toe tissue. Note that infection may be somewhat difficult to prevent in cleaning and treating ingrown nails owing to the warm, dark, and damp environment in shoes. Peroxide is immediately effective to help clean minor infections but iodine is more effective in the long term as it continues to prevent bacterial growth even after it is dry. [N.B.: Iodine should not be used on deep wounds. In such cases a physician or podiatrist should be consulted.] Also, bandages can help keep out bacteria but one should never apply any of the new types of spray-on bandages to ingrown nails that show any discharge – preventing drainage will likely cause intense swelling and pain.

It is also advisable to walk around barefoot so that air has a chance to circulate. Infections often become more painful when they are not exposed to air because bacteria grows more quickly in warmer conditions eg. when the foot is impacted tightly in a shoe.

These home remedies are, in serious cases, ineffective:
when the flesh is far too swollen and infected, it will not allow for these procedures to work. Thus, these more severe cases, such as when the area around the nail becomes infected or the nail will not grow back properly, must be treated by a professional and the patient should avoid repeated attempts at this type of ‘bathroom surgery.

Phenolisation:
Following injection of a local anaesthetic at the basis of the toenail and perhaps application of a tourniquet, the surgeon will remove (ablate) the edge of the nail growing into the flesh and destroy the matrix area with phenol to permanently and selectively ablate the matrix that is manufacturing the ingrown portion of the nail (i.e., the nail margin). This is known as a partial matrixectomy, phenolisation, phenol avulsion or partial nail avulsion with matrix phenolisation. Also, any infection is surgically drained. After this date, other suggestions on aftercare will be made, such as salt water bathing of the digit in question. The point of the procedure is that the nail does not grow back where the matrix has been cauterized and so the chances of further ingrowth are very low. The nail is slightly (usually one millimeter or so) narrower than prior to the procedure and is barely noticeable one year later. The surgery is advantageous because it can be performed in the doctor’s office under local anesthesia with minimal pain following the intervention. Also, there is no visible scar on the surgery site and a nominal chance of recurrence. The procedure will fail in about 2 to 3 times out of a hundred.

Wedge Resection
Partial removal of the nail or an offending piece of nail. More complex than a complete nail avulsion (removal).

Here, the digit is first injected with a common local anesthetic. When the area is numb, the physician will perform an onychotomy in which the nail along the edge that is growing into the skin is cut away (ablated) and the offending piece of nail is pulled out. Any infection is surgically drained. This process is referred to as a “wedge resection” or simple surgical ablation and is non-permanent (i.e., the nail will re-grow from the matrix). The entire procedure may be performed in a physician’s office and takes approximately thirty to forty-five minutes depending on the extent of the problem. The patient is allowed to go home immediately and the recovery time is anywhere from a few days to a week barring any complications such as infection. As a followup, a physician may prescribe an oral or topical antibiotic or a special soak to be used for approximately a week after the surgery……....click  & see 
A resected wedge from the left side of the left big toe, shown to scale.

It should be noted that some physicians will not perform a complete nail avulsion (removal) under any but the most extreme circumstances. In most cases, these physicians will remove both sides of a toenail (even if one side is not currently ingrown) and coat the nail matrix on both of those sides with a chemical or acid (usually phenol) to prevent re-growth. This leaves the majority of the nail intact, but ensures that the problem of ingrowth will not re-occur.

Disadvantages: If the nail matrix is not coated with the applicable chemical or acid (phenol) and is allowed to re-grow, this method is prone to failure. Also, the underlying condition can still become symptomatic as the nail grows out over the course of up to a year: the nail matrix might be manufacturing a nail that is simply too curved, thick, wide or otherwise irregular to allow for normal growth. Furthermore, the flesh can be injured very easily by concussion, tight socks, quick twisting motions while walking or just the fact the nail is growing wrongly (likely too wide). This hypersensitivity to continued injury can mean chronic ingrowth; the solution is nearly always edge avulsion by the highly successful phenolisation.

CO2 Laser surgery

Following injection of a local anaesthetic at the basis of the toe and perhaps application of a small tourniquet, the surgeon will remove (ablate) the edge of the nail growing into the flesh and cauterize the matrix area by laser photocoagulation. This too is known as a partial matrixectomy or partial nail avulsion. Here too, the point of the procedure is that the nail does NOT grow back where the matrix has been cauterized and so the chances of further ingrowth is very low. The nail is slightly (usually one millimeter or so) narrower than prior to the procedure. Disadvantages: sutures are usually necessary, post-operative pain due to the wound and scar.
…………………………….Post-surgery toe with removed nail shard

Nail Avulsion (Removal)

While in some similar cases patients may wish to have the offending nail completely temporarily removed( Avulsion) , this procedure is not recommended by nail experts because the postoperative period is long and painful. Furthermore, complete removal of whole nail does not always prevent recurrences.In case of recurrence in spite of complete removal, and if the patient never feels any pain before inflammation occurs, the condition is more likely to be onychia which is often confused for an ingrown or ingrowing nail (onychocryptosis).

Complete removal of whole nail is a simple procedure. Here, anaesthetic is injected, the nail is removed quickly and painlessly and the patient can leave immediately. The entire procedure can be performed in around 10 minutes and is much less complex than a “wedge resection” as above. Note that the nail will grow back. However, in most cases it will cause further problems as it can become ingrown very easily as the nail grows outward. It can become easily injured by concussion and in some cases grows back too thick, too wide or deformed. This procedure can thus result in chronic ingrown nails and is therefore considered a generally unsuccessful solution, especially considering the pain involved.

Accordingly, in some cases as determined by a doctor, the nail matrix is coated with a chemical (usually phenol) so none of the nail will ever grow back. This is known as a permanent or full nail avulsion , or full matrixectomy, phenolisation, or full phenol avulsion . As can be seen in the images below, the nail-less toe looks much like a normal toe and fake nails or nail varnish can still be applied to the area.


If left untreated:

If an ingrown nail is left untreated, there exists a high risk of dangerous infection. When the skin around the nail gets infected, it begins to swell up and put even more pressure against the nail. Ingrown nails can produce a spear shaped wedge of nail on the lateral side of the toe which will progressively become more embedded into the toe tissue as the nail grows forward. In the worst case, the swelling will begin putting sideways pressure on the nail, causing it to grow at a slant. This will cause both sides of the nail to eventually become ingrown and swollen. Eventually the swollen parts of the skin will begin to harden and fold over the nail. An untreated ingrown toenail will cause a person to walk with a limp, which over a long period of time may cause further pain and injury to the foot, leg and back owing to improper distribution of weight. Other non-direct effects of seriously ingrown nails include lack of exercise, constant and unrelenting pain and pressure, the spread of infection, loss of appetite, inability to move around, and psychological effects (like anxiety, stress and feelings of despair). Amputation of the toe, foot or leg may be the final outcome if the infection is left untreated long enough for gangrene to set in. An untreated infection may also lead to a condition known as osteomyelitis, where the infection spreads to the bone of the infected digit. Once in the bone, the infection is more difficult to remove and may require the intravenous treatment of antibiotics. One should always consult a doctor when infection is present.

Prevention:
The most common place for ingrown nails is in the big toe but ingrowth can occur on any nail. Ingrown nails can be avoided by cutting nails straight across; nails should not be cut along a curve, nor should they be cut too short. Footwear which is too small, either in size or width, or those with too shallow a ‘toe box’ will exacerbate any underlying problem with a toenail.

Ingrown toe nails can be caused by injury, commonly concussion where the flesh is pressed against the nail causing a small cut that swells. Also, injury to the nail can cause it to grow abnormally, making it thicker or wider than normal or even bulged or crooked. Stubbing the toenail, dropping things on the toe and ‘going through the end of your shoes’ in sports are common injuries to the digits. Injuries to the toes can be prevented by wearing shoes most of the time, especially when working or playing.

One myth is that a V should be cut in the end of the ingrown nail; this myth is untrue. The reasoning of the myth is that if one cuts a V in the nail, the edge of the nail will grow together as the nail grows out. This does not happen – the shape of the nail is determined by the growing area at the base of the toe and not by the end of the nail. {(fACT: http://www.footphysicians.com/footankleinfo/ingrown-toenail.htm DATE: September 21, 2007}}

Disclaimer: This information is not meant to be a substitute for professional medical advise or help. It is always best to consult with a Physician about serious health concerns. This information is in no way intended to diagnose or prescribe remedies.This is purely for educational purpose

Resources:
http://findarticles.com/p/articles/mi_g2603/is_0004/ai_2603000454
http://en.wikipedia.org/wiki/Ingrown_nail