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A 55 year man presented to the accident and emergency department with a bluish discoloration of his left second toe. He did not complain of any pain but had noticed the colour change while in the bath the previous evening. Three years previously he had been recognised to have type 2 (non-insulin dependent) diabetes, and was subsequently managed with a combination of diet and oral hypoglycaemic agents. He had not been seen at the diabetic clinic for nearly two years. Despite current recommendations1 he did not usually check his feet and had no regular follow up by a chiropodist.
Clinical examination showed a strong femoral pulse but absent ankle and foot pulses on the left, and black-blue discoloration of the second toe leading to a provisional diagnosis of vascular insufficiency with gangrene. A sensory peripheral neuropathy to the level of the ankle joint was demonstrated. Admission for intravenous antibiotics and angiography was arranged. A radiograph of the foot was taken to detect any changes suggestive of osteomyelitis. This demonstrated the presence of a radio-opaque foreign body (a nail) within the soft tissues of the foot (fig 1).
On further questioning the patient had no recollection of standing on a nail nor was he aware that he had any sensory disturbance in his feet. Unfortunately he required amputation of the toe and a prolonged hospital stay for repeated dressing changes and antibiotics.
This case highlights the importance of recognising that occult injury can occur in the feet of diabetics with peripheral neuropathy.2 In such patients coexistent peripheral vascular disease adds to the resultant morbidity by increasing the predisposition to infective complications. Particular attention should be paid to the possibility of painless injury and a low threshold for radiography is indicated. Follow up at a specialist diabetic foot clinic should be considered for all these patients.
We would like to thank Mr D Steedman, Consultant in Accident and Emergency Medicine, for permission to publish this case.
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