Chapter 30: Orthotic management of the neuropathic and/or dysvascular patient Flashcards
Loss of peripheral nerve function is closely associated with what?
Tissue loss because the neuropathic limb is threatened by delayed recognition of injury.
Charcot joint degeneration may result in what?
An ulcer beneath a bony prominence, or an ulcer may occur at the apex of an angular deformity such as a bunion.
Autonomic nerve loss contributes to what?
Skin breakdown by producing dry, inelastic skin due to loss of oil and sweat glands.
The loss of sensation in peripheral neuropathy is what?
Symmetrical and equidistant from the spine in both arms and legs. So hands and feet should be tested.
What is diabetic hand syndrome?
Patient shows little joint and finger mobility
What is one sign of diabetic hand syndrome?
In ability to place pronated hands flat on a table or to touch the hands together in the prayer position.
What is mononeuropathy?
Neuropathy that only affects a single nerve due to nerve trauma or entrapment
What is polyneuropathy?
Neuropathy that is a chronic disease that affects multiple nerve and presents with prickling, tingling, burning, and jabbing sensations.
Which diseases result in polyneuropathy?
Diabetes Mellitus Spina Bifida Hansen Disease (leprosy) Lupus Erythematosus. Aquired immune deficiency syndrome (AIDS) Cancer Multiple sclerosis vascular disease Charcot-Maria-Tooth disease.
What substances or conditions can cause peripheral neuropathy?
Alcoholism Arsenic Lead Steroids Gold Uremia Vitamin B deficiency Isoniazid (INH)
Patients who are unable to detect a Semmes-Weinstein monofilament of what diameter have a loss of protective sensation and are at risk of injury?
5.07 diameter (10g of force)
What are signs of concomitant dysvascularity?
Pulselessness
Decreased hair growth
Decreased skin Temperature
Gangrene
Ischemic necrosis is caused by what?
Moderate pressure (2-3 psi) over long periods of time. Local capillary circulation is interrupted, elading to skin death and ulceration. This is the mechanism of ulcer production at sites on the foot compressed by shoes that are too narrow and/or have a low toe box.
When does inflammatory destruction occur?
With repetitive moderate pressure (40-60 psi). Chronic inflammation develops and weakens the tissue, leading to ulceration. Breakdown over bony prominences occurs as a results of this mechanism.
When does penetration occur?
When a high pressure (600 psi) is suddenly applied to a small area of skin, as when stepping on a nail. Acute skin destruction also may be caused by heat or chemicals.
What helps to spread the tissue destruction?
Bacterial infection.
What is charcot joint?
A relatively painless, progressive degenerative arthropathy of single or multiple joints assoicated with neuropathy, which can be periosteal and not cutaneous, so the skin surface may have intact sensation.
What are the theories regarding charcot joint?
Multiple microtraumas to the joint that cause microfractures. These fractures lead to relaxation of the ligaments and joint destruction.
Increased blood flow related to autonomic neuropathy, leading to osteolysis and bone reabsorption. Patients with Charcot joints usually have bounding pedal pulses.
Changes in spinal cord leading to trophic changes in bones and joints.
Osteoporosis manifested by an abnormal brittleness of the bones leading to spontaneous fracture.
What is the treatment for charcot neuroarthropathy?
Casting in the neutral position for several months, followed by an orthosis such as a neuropathic walker, also known as a Charcot Restraint Orthotic Walker (CROW).
When the process becomes quiescent, the foot should be protected with appropriate shoes and inserts.
If it doesn’t become quiescent, then a permanent AFO should be made.
Calluses are a result to what?
increased local pressure or friction (shear)
Skin dryness is the result of what?
Autonomic neuropathy, in which sweat and oil production are decreased.
Loss of hair growth is a result of what?
Vascular impairment.
What increases the risk of ulceration? How?
Joint stiffness
It decreases the normal motion of the foot joints during gait, thereby increasing the foot-shoe contact pressures.
During the early/acute stages of charcot neuroarthropathy, what can be seen, what test results might be present, and what is the treatment protocol?
(It lasts 1-2 months)
The limb is painless, swollen, Red and 5-10 degrees hotter than the contralateral limb.
Laboratory tests show unhealed fractures
Treatment protocol should be total-contact cast changed 5-7 days.
During the advanced/midstage stage of charcot neuroarthropathy, what can be seen, what tests results might be present, and what is the treatment protocol?
(Last 6 months-1 year)
The limb is still warm, but with reduced swelling.
The laboratory tests show extensive bone demineralization and reabsorption
The treatment is changing of the cast every 1-2 weeks to retain the foot shape.
During the late stage of charcot neuroarthropathy, what can be seen, what test results might be present, and what is the treatment protocol?
Complete bony healing, temperature is equal to contralateral limb.
Architectural distortion with shortening and widening of the joint may be seen in tests.
The treatment is accommodation with a splint, then shoe and inserts for midfoot/forefoot deformities.
Deformities of hindfoot and ankle require a CROW boot or total contact AFO
Bony deformities may require surgery.
What doe clawed toes look like?
Dorsiflexion at the MTP joints and plantarflexion at the IP joints.
What are corns?
Hyperkeratotic lesions caused by pressure on the skin of tightly apposed toes in a moist environment.
How can corns be relieved?
With tube foam placed over the adjacent toes or lamb’s wool between the toes.
What nail deformity is common is the diabetic population?
Hypertrophy of nails caused by fungus (onychomycosis)
