8] Diabetic Wounds Flashcards
How much % of ppl with DM will develop wounds in their life?
15%
85% of those preceded by a
Foot ulcer
Mortality rate after amputation
50% within 3-5 years
Rate of ocntralateral amputation is
50% within 4 years
Of all amputations 86% could have been prevented by
Proper footwear and patient education
Diabetic wounds are on legs or feet?
FEET
Neuropathic wounds - sensory
Loss of protective sensation
Neuropathic wounds- motor
Wasting of intrinsic muscles of foot and structural deformities
Neuropathic wounds- autonomic
Dry, cracked skin due to decreased sweating, decreased lubrication, fissures
Most commonly affected area of diabetic
Great toe
Order of affects with diabetic foot ulcers
Great toe - 30% 1st met head- 22% Dorsum of digits - 13% Plantar surface of other toes- 10% 5th met head- 9%
Etiology of diabetic foot ulcer
Neuropathy + ischemia + Structural
changes = abnormal pressure points and repeated trauma
Risk factors of diabetic foot ulcer
- Poor glucose control
- Loss of protective sensation
- Progressive shape changes of foot
- Poor foot wear
Wagner is for what?
Grading foot ulcers on a scale of 0 - 5
What is Wagner grade 0
Damage to foot but skin intact
Treatment for grade 0 Wagner
Protection (TCC, orthotic, footwear)
Grade 1 Wagner
Superficial or partial-thickness ulcer
Treatment for grade 1
Local wound care, manage edema, protect from maceration, foot protection
Wagner grade 2
Full thickness wound with subcutaneous involvement
Treatment for grade 2 Wagner
Local wound care, manage edema, protect from
maceration, foot protection
Grade 3 Wagner
Infection (abscess, osteomyelitis)
Treat for grade 3 Wagner
Refer to ortho surgery for I&D or resection of bone
Wagner grade 4
Gangrene of forefoot
Treat for grade 4 Wagner
Refer to vascular surgeon for re-vascularization or amputation
Grade 5 Wagner
Gangrene of most of the foot
Treat for Wagner grade 5
Refer to vascular surgeon fr re-vascularization or amputation
Characteristics of diabetic foot wounds
Plantar aspect of the foot,
particularly the metatarsal
heads, plantar heels, or toes
Are there tropic changes in diabetic foot wounds
Yes
What kind of wound bed with diabetic foot wounds
Deep, pale wound bed with some necrotic tissue
What kind of edges?
Smoot edges with callus rim
How much drainage?
Low to moderate
If infection happens, which is common, suspect what?
Osteo
Risk factors for Charcot foot
Ages 50-60 Diabetic for more than 10 years Peripheral neuropathy Loss of protective sensation Nephropathy Retinopathy
Progressive condition
characterized by joint
dislocations, pathologicfractures, and
deformities.
Charcot foot
Charcot foot is most common where
Foot and ankle
Characteristics of Charcot foot
Edema Erythema Skin temperature difference of 6.7 degrees Bony prominences at midfoot Ulcerations common at midfoot
When would you suspect osteomyelitis?
When they have had an ulcer longer than 1 month
What should be palpable with osteo?
Bone
Recurrent ulcer for osteomyelitis is in ?
Same location
Osteomyelitis and Charcot foot will both be
Red, warm, edematous and painful
What’s the biggest difference between osteo and Charcot?
A bone scan and bone biopsy will be + for osteomyelitis. Charcot foot would be negative.
Elevated WBC count withdifferential
Osteomyelitis
May have mildly
elevated WBC/ESR
Charcot foot
Elevated ESR
Osteomyelitis
Elevation of the foot for 1-2 hours should
eliminate erythema and swelling
Charcot foot
(+) Bone scan with WBC labeling
(+)Bone biopsy
Gold standard
Osteomyelitis
due to
loss of nourishment to a part, followed by
mummification
Dry gangrene
necrosisof tissue followed by
destruction caused by
excessive moisture
Wet gangrene
What accumulates in the tissue of wet gangrene
Bacterial gases
Line of demarcation isill-defined and limb is painful, purple and
swollen
Wet gangrene
pulses/Doppler, rubor of dependency, ABI – not reliable in DM history of claudication ischemic pain
Vascular status
24% healed at ?
12 weeks
47% healed at ?
20 weeks
If the wound has not healed by 50% in the first4 weeks of treatment, only ???
9% chance it will heal in 3 months
Treat cuts right away by
Washing with soap and water and covering with sterile gauze
3 types of debridement intervention
Sharp
Enzymatic
Autolytic
Scalpel; may be surgical (gold standard)
Sharp debridement
Uses medication to break down necrotic tissue
Enzymatic debridement
What increases the chances of DFU healing?
Adequate off-loading
What’s the preferred method for offloading diabetic plantar foot ulcers?
Total contact casting
Advanced therapeutics are unlikely to succeed in improving wound healing outcomes unless ?
Off-loading is achieved
How often are total contact casting replaced?
Weekly if theres no swelling or drainage. 2-3 days if there is.
Advantages of total contact casting
Protects from trauma
Reduces edema
Offloads forefoot and midfoot
Is total contact casting removable?
NO
Disadvantage of total contact casting
- heavy, hot,
bathing/walking/sleeping difficult - Has healing rate of 90% within 6-8weeks
- its considered a fall risk
Contraindications for TCC
- Documented peripheral arterial disease ABI < 0.7 Active infection Fluctuating leg edema Osteomyelitis Necrosis in wound Sinus tract with deep extension into foot
What does CROW stand for
Charcot restraint orthotic walker
What is a crow?
Rigid polypropylene bootwalker with rocker sole
What does a crow do?
Reduces pressure and shear
What is a DH pressure relief walker?
Removable walking boot with rocker-bottom sole
Advantage of DH pressure relief walker
Easy to apply, adjusts to edema, wound can be inspected regularly, inexpensive
Disadvantage
No forced compliance
Orthowedge healing shoe
Removes forefoot weight bearing
Orthowedge healing shoe is used for?
Forefoot wound or s/p digit or forefoot amputation
What angle is the orthowedge healing shoe
10 degree DF angle
