Neuropathic Ulcers Flashcards
(91 cards)
1
Q
How many Americans have diabetes?
A
over 24 million
2
Q
Incidence of neuropathic ulcerations:
A
15-25%
3
Q
How many amputations is diabetes responsible for a year?
A
600,000
4
Q
Symptoms of hyperglycemia
A
frequent urination
increased thirst
increased hunger.
5
Q
Acutecomplications of DM:
A
Diabetic ketoacidosis
Nonketotic hyperosmolar coma
6
Q
Long term complications of DM:
A
Heart disease Stroke Chronic kidney failure Foot ulcers Visual impairment
7
Q
Type 1 DM:
A
Diagnosed in children or young adults
Results from an immune mediated destruction of pancreatic beta cells
Pancreas is becomes unable to produce insulin
8
Q
Type 2 DM:
A
Diagnosed at middle age or later
Approximately 80% of diagnosed are overweight
Genetic predisposition to developing type 2
Start as “insulin resistance” where cells in the body do not respond properly to insulin
Excessive weight and inadequate physical activity are contributing factors
9
Q
Hyperglycemia
A
Changes RBCs, platelets, and capillaries
Alters blood flow
Increases microvascular pressure
10
Q
What do glycosylated proteins cause?
A
tissue trauma
11
Q
What is accumulation of sorbitol due to?
A
to breakdown of glucose, results in tissue destruction
12
Q
Where are diabetic wounds located?
A
Usually on tips of toes, lateral aspect of foot dorsum of foot, metatarsal heads especially 1st and 5th, heels, midfoot and at location of orthopedic deformity
13
Q
What percentage of diabetic ulcers are neuropathic foot ulcers?
A
60-70%
15-20% of diabetic ulcers are from PVD
15-20% are mixed cause
14
Q
Wound edges:
A
even, well defined, with and without undermining
15
Q
What deformity is common in diabetic foot ulcers?
A
Hammer toe/claw toe
16
Q
Skin changes with DM:
A
Cracking; callous formation
17
Q
Reasons for delayed wound healing in DM:
A
Inhibited fibroblast activity Inhibited endothelial cell activity Decreased collagen deposition Delayed re-epithelialization Decreased re-endothelialization of microarterial anastomoses
18
Q
Diabetic Risk Factors Contributing Delayed Healing and Neuropathic Ulcers
A
Vascular disease Neuropathy Mechanical stress Abnormal foot function and inadequate footwear Impaired healing and immune response Poor vision
19
Q
Vascular Disease
A
Risk for PVD greater in patients with diabetes
Accelerated atherosclerosis
Thickening of basement membrane
20
Q
Neuropathy
A
Most common complication of diabetes
Symmetrical, distal
Affects sensory, motor, and autonomic systems
21
Q
Causes of neuropathy:
A
Neural ischemia
Segmental demyelination
22
Q
Sensory neuropathy:
A
the most common type of diabetic neuropathy
causes pain or loss of feeling in the toes, feet, legs, hands, and arms
23
Q
Autonomic neuropathy
A
causes changes in digestion, bowel and bladder function, sexual response, and perspiration
Can affect the nerves that serve the heart and control blood pressure, as well as nerves in the lungs and eyes
24
Q
Motor neuropathy
A
Results in muscle atrophy and weakness Intrinsic muscle weakness/atrophy Decreases foot stability Leads to deformities Increased pressure and shear forces to foot
25
Sensory Neuropathy
50% of patients unaware they have lost protective sensation
Lack of protective sensation = lack of early detection to irritation or trauma
Paresthesias
26
At risk for pressure ulceration:
If unable to perceive 10g of pressure
27
Autonomic Neuropathy Ulcers:
Dry, cracked skin due to decreased ability to sweat
Increased rate of callus formation
Arteriovenous shunting leads to decreased perfusion
Uncontrolled vasodilation leads to osteopenia
28
Charcot foot
cycle of fracture and healing-
29
What happens in acute destructive phase of charcot foot?
inflammation, sublexation, bone fragments, fractures (deformity can be controlled in this phase)-
30
What does the acute destructive phase of charcot foot result in?
```
Increased blood glucose
Peripheral neuropathy
Mechanical stress
Ankle equinus
Autonomic neuropathy causing increased blood flow resulting in osteolysis, osteopenia
Trauma
```
31
Mechanical Stress
Abnormal or excessive forces predispose to ulceration
| High plantar pressures overload tissue’s ability to repair itself
32
Abnormal Foot Function and Inadequate Footwear
Impaired ROM
Foot deformities
Prior ulcer/amputation
Poor footwear
33
Impaired ROM
Great toe ext, DF, subtalar joint
| Increase vertical pressure and horizontal shear
34
Foot deformities
PF contracture, varus/valgus, Charcot foot
35
Impaired Healing and Immune Response
Decreased ability to build new tissue and fight infection
Decreased ability to fight infection
Increased frequency of osteomyelitis, soft tissue infections, candida
Impairs all 3 phases of wound healing
36
Poor Vision
Diabetes is leading cause of retinopathy, glaucoma, cataracts
Increases risk of trauma
Decreases ability to perform adequate foot care
37
Ulcer Characteristics
Larger and deeper wounds take longer to heal
| Wounds present for longer time take longer to heal
38
Disease Characteristics
Poor glycemic control associated with increased risk of long-term complications
Complications can be improved/reversed with improved glycemic control
39
Inadequate Care and Education
Lack of cutting-edge knowledge
Delayed referrals
Poor adherence to clinical guidelines
Minor short-term complications but major long-term complications
Patients do not understand link between hyperglycemia and long-term complications
Absence of pain or short-term effects decreases patient adherence
40
PT Tests and Measures
| for Neuropathic Ulcers
Circulation
| Sensory integrity
41
Circulation:
```
Pulses
Capillary refill
Doppler ultrasound
Ankle-Brachial Index
TCPO2
```
42
Sensory integrity
Sensation to light touch
| Sensation to vibration
43
Indications of circulation:
All open wounds
Decreased or absent pulses
Signs and symptoms of arterial insufficiency
History of PVD
44
Semmes-Weinstein Monofilaments
```
Occlude patient’s vision
Begin with 5.07 monofilament
Avoid calloused areas
Each location tested randomly 3x
At least 1 sham application at each point
```
45
Sensory Integrity indications:
All neuropathic ulcers
All patients with diabetes
All patients with plantar foot ulcers
46
Monofilament 4.17
Pressure produced: 1 gram
| inability to feel: decreased sensation
47
Monofilament 5.07
10 grams of pressure
| loss of protective sensation
48
Monofilament 6.10
75 grams of pressure
| absent sensation
49
How many incorrect response with tunning fork indicates peripheral neuropathy?
at least 5
50
Grade 0 Wagner:
No open lesions
May have deformity or cellulitis
Integumentary Practice Pattern A (at risk)
or B (superficial skin involvement)
51
Grade 1 Wagner:
Superficial ulcer
| Integumentary Practice Pattern C (partial thickness) or D (full thickness)
52
Grade 2 Wagner:
Deep ulcer to tendon, capsule, bone
53
Grade 3 Wagner:
Deep ulcer with abcess, osteomyelitis, or joint sepsis
54
Grade 4 Wagner:
Localized gangrene
55
Grade 5 Wagner:
Gangrene of the entire foot
56
“5PT” Method
```
Pain
Position
Presentation
Periwound
Pulses
Temperature
```
57
Pain
Lack of pain complaint due to neuropathy
| Possible paresthesias
58
Position
Plantar foot
Plantar aspect of metatarsal heads
Plantar aspect of midfoot if Charcot deformity
May occur under calluses
May occur in areas of pressure/friction from inappropriate footwear
59
Presentation
Round, punched-out lesions
Callused rim
Minimal drainage unless infected
Eschar or necrotic material uncommon unless infected
60
Periwound and Structural Changes
```
Skin is dry, cracked
Callus present
Structural deformities
Claw toes
Rocker-bottom foot
Prior amputation
```
61
Pulses
Normal
| May be accentuated with vessel calcification
62
Temperature
Normal
| May be increased in areas of reactive hyperemia or infection
63
Good healing
smaller, superficial wound (Wagner 1 or 2)
present for less than 2 months
ulcers decreasing in size within 4 weeks of treatment
64
Poor healing:
large size
Risk of amputation 154x greater with infected ulcers
If 20–50% decrease in size not noted in first month of treatment
65
Average healing time of DU:
Large variability in healing rates
| Average healing time 12–14 weeks
66
Patient/Client-Related Instruction
```
Disease process/management of DM
Role of exercise and safety guidelines
Risk factor reduction
Daily foot checks
Foot care guidelines
```
67
PT precautions:
May not show signs of infection due to decreased inflammatory response/PVD
Request culture and sensitivity for wounds that fail to respond to appropriate interventions
Osteomyelitis must be treated surgically
68
Intervention Goals
Tight blood glucose control
Off-loading
Aggressive debridement if arterial supply intact to decrease microbial load and remove senescent cells/biofilm
Removal of callous and irregular wound edges to allow healing from borders
69
Monitor blood sugar
Hyperglycemia common with infections and uncontrolled diabetes
Hypoglycemia may occur
Optimal Glucose < 150
>180 inhibits neutrophil activity
70
Off-Loading
Avoidance of all mechanical stress on injured extremity, essential for healing
Trauma causes most plantar wounds and ongoing trauma prevents healing
71
Total Contact Casting:
Cast is molded to foot and leg, dispersing weight-bearing forces over large area
Cast rigidity controls edema
Immobilization of foot protects from trauma and microorganisms
Assists with patient adherence
72
How does total contact casting heal wounds?
by reducing weightbearing pressure and shear force to the plantar aspect of the foot
Minimal padding
Maintains “total contact” with the foot and lower leg.
Closely molded
73
Contraindications to total contact casting?
```
Osteomyelitis
Gangrene
Fluctuating edema
Active infection
ABI less than 0.45
```
74
Gait and Mobility Training
```
PWB gait with assistive device
Alter gait pattern to decrease plantar pressure
Step-to pattern
Slower steps
Shuffling gait
Footwear modifications
```
75
Off-loading devices
Crutches, wheelchair
Wedge shoes
Total contact casts
Prefabricated cast walker
76
Pressure relief
Orthotics
Cushions
Positioning
77
Options for temporary footwear:
Felt or foam inserts
Padded ankle-foot orthoses
Walking shoes
78
Benefits of temporary footwear:
Provides safe ambulation, pressure reduction, room for bandages
Can use when total contact cast is not an option
79
Wedge Shoe
reduces weight bearing pressure on the forefoot which promotes faster healing after surgery, trauma or when forefoot wounds or ulcerations are present.
80
DARCO HeelWedge
Off-loads pressure from the heel by shifting weight to the mid and forefoot to promote faster healing after surgery, trauma or when wounds or ulcerations are present on the heel
81
Wound Care Shoe System
Deep rocker sole
Four layers of differing density insoles that may be altered for off-loading
Leather upper lined with Plastazote® material
Sections may be removed from the leather upper without disturbing the liner to remove pressure
82
Prefabricated cast walker
Custom inflated aircells for individual fit and support
Rocker bottom and rigid sole
Allow forward progression in gait without transferring forces to the forefoot
83
Permanent Footwear dimensions:
Shoes should be ~½ inch longer than the longest toe with snug heel fit
Shoe last should match foot shape
Extra-depth toe box
Heel height < 1 inch
84
Permanent Footwear
```
Soft, moldable materials
Soft inserts may decrease pressure
Fit shoes at the middle of the day
Break in shoes gradually
Patients with severe foot deformities or amputations should be referred to an orthotist
```
85
Orthotics
Used to correct foot deformities and equalize pressure to prevent ulceration
86
Therapeutic exercise:
ROM
| Aerobic
87
ROM Exercises
Assess/address great toe extension, talocrural dorsiflexion, and subtalar joint motion
Joint mobilizations may be helpful
88
Aerobic Exercise:
Assists with glycemic control
| Assists with weight loss
89
Medical Interventions
Glycemic control
Even 1% decrease in hemoglobin A1c associated with improvements in many complications
Manage neuropathic pain/paresthesias
Anticonvulsants, antidepressants, capsaicin
Management of concomitant arterial insufficiency
Antibiotic therapy
Cultures of neuropathic ulcers average 4–5 different microbes
Most commonly group A Strep and Staph aureus
Radiological assessment
Fracture identification – Charcot foot
Presence of foreign bodies
Bone scan for osteomyelitis
90
Surgical Interventions
```
Debridement
Necrotic tissue
Osteomyelitis
Incision and drainage
Antimicrobial bead implantation
```
91
Who would be indicated for surgical interventions:
```
Surgery to address abnormal foot function or limited tissue perfusion
Joint arthroplasty
Tendon lengthening
Stabilization of Charcot deformities and reduction of abnormal biomechanics
Revascularization surgery
Amputation
Gangrene
Wagner grade 4 or 5 ulcers
```
