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MD2 Endocrine > Foot Ulcer > Flashcards

Foot Ulcer Flashcards

1
Q

DDx for this ulcer

A

Malignancy (melanoma, SCC)

Vasculitis

Dermatological condition: pyoderma granulosum

Infectious: Hansen’s disease, syphilis, deep seated infection, osteomyelitis

DM

Trauma: chemical, thermal, pysical

PVD

Venous insufficiency

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2
Q

What factors contribute to ulceration in DM?

A

Loss of pressure and pain sensation

Dry skin

Reduced joint mobility

Structural deformity

Poor balance and instability

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3
Q

How can ulcers be treated initially?

A

Treat any cellulitis with IV Abx

Surgical debridement

Trial of maggot therapy

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4
Q

What are the 5 essential components to clinically assess, Ix and manage in order to treat and prevent recurrence of diabetic foot complications?

A

Peripheral neuropathy

PVD

Ulceration

Infection

Maximise diabetes control

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5
Q

What measures can be taken in an attempt to prevent the formation of pressure ulcers during admission of neuropathic patients?

A

Pressure off-loading with air mattress

Orthotics (in order of efficacy): CAM walker, total contact cast, half shoe

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6
Q

What is the Ix of choice for diabetes-related critical limb ischaemia (evidence of ulceration or gangrene)? What other Ix can be performed? What Mx is indicated?

A

Angiography

Ix: duplex U/S, toe pressures (less than 45mmHg indicates ulcer is unlikely to heal), transcutaneous O2 (less than 30mmHg indicates ulcer is unlikely to heal)

Mx: determine suitability for PTA, bypass

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7
Q

What are the clinical signs of an infected ulcer?

A

Purulent discharge (pus)

Two or more: pain/tenderness, swelling, redness, warmth

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8
Q

What clinical signs suggest osteomyelitis?

A

Prolonged ulcer duration

Recurrence of ulceration at same site

Can occur post-surgical intervention

“Sausage toe”: toe swollen with non-pitting oedema, uerythematous, obliteration of contours

Probes to bone or bone on show

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9
Q

What serological markers of infection raise with a severely infected ulcer?

A

RBG

WCC

ESR

CRP

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10
Q

What biochemical markers may suggest osteomyelitis?

A

ALP

Prevalence of osteomyelitis increases with ESR (100% of patients with ESR >70mm/hr had osteomyelitis with no signs of infection on examination)

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11
Q

How can osteomyelitis can be diagnosed radiologically?

A

XR (but time delay for changes to appear)

Tc99 bone scan: more sensitive but non-specific

WBC scans: higher specificity but less sensitive than Tc99

MRI: most useful for making Dx and defining extent of infection

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12
Q

How should a bone biopsy be obtained in the setting of osteomyelitis?

A

Obtained through uninfected skin

If able, discontinue Abx for 48 hrs prior

Send off sample for histopathology and MCS to guide Abx use (improves outcomes)

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13
Q

Wound Mx TIME principle

A

Tissue non viable: remove defective tissue (sharp/autolytic/larval)

Inflammation or infection: remove or reduce bacterial load

Moisture imbalance: restore

Edge of wound not advancing: address T/I/M issues

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14
Q

What treatment is indicated for a diabetic ulcer with underlying osteomyelitis with # of fibula at ankle joint?

A

BKA

Rehabilitation

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15
Q

What is the role of amputee rehab?

A

Return a person to maximal physical, psychological, social and vocational function

Minimise disability and handicap

Improve prosthetic (artificial limb) acquisition

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16
Q

What are the 7 phases of amputee rehabilitation?

A

Pre-operative

Acute post-surgical

Pre-prosthetic

Prosthetic design

Prosthetic gait training

Community integration

Follow-up

17
Q

What aspects of amputee rehabilitation begin pre-operatively?

A

Pre-op consultation with rehab specialist to discuss:

Amputation level

Functional expectations

Rehabilitation processes and timeframes

Suitability for prosthesis

Phantom limb pain (PLP) and sensation

18
Q

What 4 factors influence prosthetic acquisition following amputation?

A

Physical fitness

Fewer comorbidities

Ability to stand on remaining leg

Motivated to walk

19
Q

What % of diabetic amputees have a contralateral amputation within 2-5 years?

A

50%

And within 2 years, 15% transtibial amputations are converted to transfemoral and 30% of patients are dead

20
Q

What is phantom limb pain (PLP)? What factors can aggravate it and what treatments are used to manage it?

A

Pain sensation localising to missing extremity or body part; variable in severity and subject description, onset usually within a week

Aggravated by local factors e.g. wound infection, general medical problems

Mx: medication, physical modalities (massage, TENS), psychological (distraction)

21
Q

What is phantom limb sensation (PLS) and why is it important?

A

Any sensation in absent limb except pain

Can contribute to falls

22
Q

What are the goals of inpatient rehabilitation post-amputation?

A

Wound healing

Residual limb (“stump”) care

Pain Mx

Thrombo-embolism prophylaxis

Establish bowel and bladder program

Care of other foot, joint preservation

Mx of co-morbidities (e.g. IHD)

Optimisation of CV RFs

Goals: walking independently, able to mobilise around home as needed (including upstairs if relevant), preventing or reversing deconditioning after prolonged immobility, minimising falls risk, ensuring independent with ADLs, providing education and emotional support

23
Q

Who is involved in the amputee rehabilitation team?

A

Prosthetist and orthotist

OT

Physio

Nurse and wound nurse

Surgeon

Endocrinologist

Dietician

Psychologist

Diabetes educator

SW

Podiatrist

Rehab physician

Patient and family!

24
Q

What is an RRD and what does it do?

A

Removable rigid dressing

Fitted by prosthetist to reduce oedema, protect stump from trauma and decrease pain

25
Q

What FU is indicated for amputees?

A

Life-long amputee rehab clinic FU: comorbidities and contralateral foot care, residual limb skin problems (common), prosthetic needs/replacement, pain Mx, activity limitations and participation restrictions, equipment needs, psychological support

26
Q

What steps must be taken before a new amputee can return to driving?

A

Requires OT driving assessment

Auto only, L foot accelerator and brake control

27
Q

What steps are indicated in the return to work for a new amputee?

A

Consider need for waterproof leg

May require a foot/ankle modular component of prosthesis which works better on uneven ground

No lifting or transporting >18kg

MD2 Endocrine (11 decks)

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