39/40: Ulcerations - Bennett Flashcards Preview

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define skin ulcer

A wound with complete loss of
the epidermal layer of skin
with extension into the dermis
and possibly the subcutaneous


most common single precursor to lower extremity amputations among persons with diabetes

foot ulcerations


big three complications of diabetes

- blindness
- kidney failure
- foot and leg amputation


"intrinsic minus foot"

foot deformity in diabetes due to motor neuropathy
- hammertoes
- bunions
- prominent met heads
- ankle equinus
- instability
- charcot


why is diabetic skin dehydrated?

- autonomic neuropathy
- put at greater risk for skin breakdown


describe diabetic demopathy

- xerotic, non-supple dkin
- fissuring, calluses
- more susceptible to infections


describe diabetic nails

- nails thickened, brittle
- ingrown nails (can be initial event to toe amputation)


Recommended visits for Diabetic patients based on neuropathy level

none = annual (0)
neuropathy = semi-annual (1)
neuropahty, PVD and/or deformity = quarterly (2)
previous ulcer or amputation (3) = monthly to quarterly


why no lotion b/w toes?

- if excess, can cause breakdown of the skin
- can use if rub in properly


what do you need to tell your patient about topical nail medication?

- file nail weekly and apply daily
- take off weekly with nail polish remover
- works on new nail growth
- may take 9 month to see effect


what should you not use for corns/calluses

- sharp blade removal (use pumice stone)
- medicated corn pads (acid)


what time of the day should you get shoes?

- swell throughout the day


what do you need to describe about an ulcer?

- location
- size and depth *
- margins
- base
- undermining (skin is healing over top, but not attached, 'lip')
- sinus tracts
- probing to bone
- erythema, edema, malodor, purulence, ascending lymphangitis


fibrotic base, crusting around wound, maceration, erythema around wound

venous stasis wound


Wagner ulcer classification ****

Grade 0: pre-ulcerative lesion

Grade 1: superficial without subcutaneous involvement

Grade 2: penetration through subcutaneous tissue (may expose bone, tendon, ligament, joint capsule) *** may probe to bone but no infection

Grade 3: Osteitis, abscess, or osteomyelitis *** underlying infection

Grade 4: Gangrene of forefoot

Grade 5: Gangrene of entire foot


University of Texas Wound Classification

Grade 0- III
Stage A-D

grade first, then stage

0 = pre- or postulcerative lesion completely epitheliazed
I = superficial wound, not involving tendon, capsule or bone
II = wound penetrating to tendon or capsule
III = wound penetrating to bone or jointn

A = no infection or ischemia
B = infected
C = ischemic
D = infected and ischemic


NPUAP staging

Suspected Deep Tissue Injury = Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.

Stage 1 = Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area

Stage 2 = Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.

Stage 3 = Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling

stage 4 = Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling

Unstageable = Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.


what are the principles of ulcer management? ***

1. infection
2. vascular supply
3. debridement
4. off-loading
5. wound management
6. wound closure
7. management of medical comorbidities


systemic symptoms of infections

- Fever, chills, nausea, vomiting
- Leukocytosis (may not be present)
- Blood glucose levels out of control


localized symptoms of infections

Erythema, edema, calor, pain, purulence, lymphangitis, malodor


what imaging will let you see an abscess?

MRI not x-ray


how do you culture a possible foot infection?

- deep swab
- collection of purulence
- deep tissue culture is best


if you suspect a bone infection ..

bone biopsy is best


general treatment of foot infection

- incision and drainage debridement to eradicate bacterial load done wet (to find the good/bad tissue based on bleeding)
- empirical antibiotics then focus


when do you use antibiotic beads?

- infected bone that can't be removed
- limits a lot of systemic toxicity vs. oral or IV antibiotics


how often does surgical debridement need to occur?

every 48 hrs until necrotic tissue is eradicated (based on what you see - could be more or less)


4 types of wound debridement

- autolytic (use own fluids to debride, "wet to dry")
- enzymatic (chemicals debride necrotic tissue, faster than autolytic)
- biotherapy (medicinal maggots, only necrotic
- mechanical (surgical)


moist or dry wound management?

"if its dry, wet it; if it's wet, dry it"

The literature overwhelming supports the use of moist wound healing, and severely criticizes any attempts to desiccate a wound, especially with topical antibiotics such as betadine


reconstructive ladder of wound closure

1. Secondary Intention
- skin equivalents
2. Primary Closure (3:1 length width ratio)
3. Split thickness (better) or full thickness skin graft
4. Rotation or advancement local random flap
5. Transfer pedicled flap
6. Transfer autogenous microvascular free flap


what is the goal ejection fraction for perfusion?

55% and above