Neuropathic Ulcers/Diabetic Foot Management

Question 1

Types of neuropathy: characteristics and significance of each (in terms of risk for breakdown principles of management to include importance of glucose control and impact of hyperglycemia on infection control) and offloading

Answer 1

SENSORY Neuropathy: LOPS, painless trauma
Semmes-Weinstein monofiliaments (LOPS) #5.07, #6.10 (insensate)
Loss of Vibratory sensation precedes LOPS, tuning fork
Loss of Proprioceptive sense

MOTOR Neuropathy: nerve damage to muscle
muscle atrophy, foot/toe deformities, altered wt-bearing
claw toes, hammer toes, gait changes, thinning fat pads
= tissue trauma (inspect for foot deformities, altered contours, callus formation

AUTONOMIC Neuropathy: nerve damage to sweat glands, diameter of blood vessels
dry, cracked feet
increase blood flow flow = osteopenia (#)
Charcot foot
Ax wet (rare hyperhidrosis) or dry feet

Glucose control Normal = 100-140 d/L (keep

Question 2

Critical parameters to be included when assessing the diabetic foot (e.g., vascular status, sensory status) and utilization of findings to individualize patient education; strategies for dealing with hypertrophic nails (thinning with Dremel drill); mechanisms for dealing with corns and callouses (paring with scalpel/smoothing with drill)
modification of footwear to prevent recurrence

Answer 2

Vascular Status (color, temp, hair growth, skin status, cap refill, pulses, ABPI, edema)

Sensory Status (monofiliament #5.07/#6.10)
Hypertrophic nails: foot soaks, podiatrist consult 

Dremel drill (thin nails)

Corns/callouses (pare down with scapel)

Offloading footwear

Question 3

Management strategies to prevent deterioration of neuropathic ulcers: aggressive debridement and infection control

Answer 3

**aggressive debridement of all necrotic tissue
early aggressive Tx of Ix to minimize limb loss
principles of wound healing
Pressure relief for heel ulcers
* Offloading plantar surfaces
* Control glucose
Appropriate topical tx
Pt education glucose control, wound care, *Protective care(prevent further trauma)
Regular foot care
Second line therapy (GF, HBOT, engineered tissue if no progression)

Question 4

Describe the difference between offloading with devices vs orthotics use for pre-ulcerative lesions

Answer 4

Offloading (evenly distribute pressures, decrease stress forces, protects)
1. Total Contact Casting
2. Removable cast walkers
3. Poor man’s total contact cast (anecdotal)
Orthotics cannot be used to treat ulceration