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Surgery M4 part 1 > DF, Gangrene, Leg Ulcers > Flashcards

DF, Gangrene, Leg Ulcers Flashcards

1
Q

What are the pathologies associated with diabetic foot?

A
  • neuropathy
  • vasculopathy
  • diabetic (neuropathic) ulcer
  • diabetic foot infections
  • gangrene
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2
Q

What causes the glove & socks hypothesia?

A

interacting metabolic abnormalities worsened by injury of vasa nervorum:
Sensory neuropathy in distal nerve fibers (loss of protective sensation leads to lack of awareness of incipient or ulceration)

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3
Q

What are the affects of motor neuropathy?

A

1- alteration of distribution of forces during walking
2- reactive thickening of skin (callus) at sites of abnormal load
3- ischemic necrosis of tissues beneath callus
4- neuropathic ulcer

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4
Q

How does Charcot foot of diabetes develop?

A

AUTONOMIC NEUROPATHY

osteoporosis

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5
Q

What are the types of vasculopathy?

A 
Macrovascular disease (due to atherosclerosis) 
Microvascular disease
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6
Q

What is the pathophysiology of microvascular disease?

A

STRUCTURAL

  • thickened basement membrane
  • capillary wall fragility
  • thrombosis

FUNCTIONAL (vasomotor neuropathy)

  • defective microcirculation
  • abnormal endothelial function
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7
Q

How is vasculopathy managed?

A
  • antiplatelet
  • vasodilators
  • pentoxyphylline
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8
Q

What are the routes of infection entry leading to DF?

A
  • skin fissuring & cracks
  • fungal infection (tinea pedis)
  • ulcers
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9
Q

What are the predisposing factors to Diabetic foot?

A
  • hyperglycemia
  • ischemic tissues
  • neuropathy
  • poor immune system
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10
Q

What is the clinical picture of DF?

A
  • general: from mild to septic shock
  • local: hot, red, tender swelling, may have pus
  • due to peripheral neuropathy the presentation may be offensive odor or tissue destruction (sloughing & ulcers)
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11
Q

What is the most important laboratory investigation in case of DF?

A

SWAB & CULTURE/SENSITIVITY (to use appropriate antibiotic)

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12
Q

What radiological investigations are used in case of diabetic foot?

A

XRAY: to detect chronic osteomyelitis & joint destruction (Charcot’s joint)
DUPLEX: to assess vascularity
MRI: to assess extent of soft tissue involvement

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13
Q

What is the investigation of choice to see soft tissue involvement?

A

MRI

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14
Q

What is Wagner’s classification system?

A

0: pre ulcerative area
1: superficial ulcer (partial/full thickness)
2: ulcer deep to tendon, capsule, bone
3: 2 + abscess, osteomyelitis or joint sepsis
4: localized gangrene
5: global foot gangrene

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15
Q

What is the first & most important line of prophylaxis against DF?

A

proper control of blood glucose

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16
Q

How should DF be prevented?

A
  • control of blood glucose
  • care of foot
  • establishment of good vascularity (vasodilators, antiplatelets, vitamins)
  • regular exercise
17
Q

What is the medical treatment for diabetic foot?

A

1- limb elevation
2- hot fomentation
3- correction of hyperglycemia: shift to insulin
4- antibiotics (PARENTERAL ROUTE)
- start with broad-spectrum empirical then according to C&S

17
Q

What is the medical treatment for diabetic foot?

A

1- limb elevation
2- hot fomentation
3- correction of hyperglycemia: shift to insulin
4- antibiotics (PARENTERAL ROUTE)
- start with broad-spectrum empirical then according to C&S

18
Q

What is the surgical treatment of DF?

A
  • GENEROUS DEBRIDEMENT
  • under general anesthesia
  • adequate incision & drainage of any pus
  • excise any necrotic tissue
  • removal of all callus (sequestrum)
19
Q

How should a wound or ulcer be managed in a diabetic patient?

A
  • daily irrigation of exudation with saline
  • daily dressing with topical antiseptic
  • avoid excessive packing
  • remove any new necrotic tissue & incise any new pus collection
  • off-loading measures (eliminate any plantar pressure on the wound/ulcer)
    • total contact casting
    • removable cast walkers
    • ankle foot orthosis
    • custom & surgical shoes
20
Q

What is gangrene & what are its types?

A

macroscopic necrosis (tissue death) + putrefaction

types:

  • dry
  • moist
  • special: gas gangrene, bed sores, Fournier’s gangrene, necrotizing fasciitis
21
Q

What is the difference between dry & moist gangrene?

A

DRY MOIST

  • chronic ischemia - acute ischemia or chronic ischemia with underlying edema or infection
  • minimal putrefaction - marked
  • minimal odor - very offensive
  • line of demarcation - no line (severe toxemia)
  • absent skipped lesions - present
  • if small: autoseparation - amputation until level of good vascularity
  • if large: amputation
22
Q

What is Fournier’s gangrene?

A
  • idiopathic gangrene (necrotizing fasciitis) of the scrotum
  • due to synergistic infection
  • affects scrotum but spares testis
23
Q

How is Fournier’s gangrene treated?

A

debridement & scrotal reconstruction

24
Q

What is an ulcer?

A

loss of epithelial cover

25
Q

How should an ulcer be inspected?

A
  • site
  • size
  • shape
  • number
  • floor
  • edge
  • margin & surrounding skin
  • discharge
26
Q

What are the different sites of ulcers & their causes?

A
  • UPPER FACE: basal cell carcinoma
  • LOWER LIP: squamous cell carcinoma
  • ABOVE MEDIAL MALLEOLUS: venous ulcer
  • DISTAL PART OF LOWER LIMB: ischemic ulcer
  • PRESSURE POINTS: neuropathic ulcer
27
Q

What can be inspected in the floor of an ulcer?

A
  • red granulation tissue: healthy ulcer
  • white necrotic material/pyogenic membrane: unhealthy ulcer
  • wash-leather slough: syphilitic gumma
  • caseating material: TB
28
Q

What are the different edges of an ulcer?

A
  • Shelving (sloping): healing ulcer
  • Punched out:
  • Undermined: TB
  • raised & everted: SCC
  • rolled in & beaded: BCC
29
Q

What could be seen around the margin of an ulcer?

A
  • pigmentation & eczema: venous ulcer
  • trophic changes: ischemic ulcer
  • cyanotic: TB
30
Q

What does discharge indicate in an ulcer?

A
  • purulent: active infection
  • green: pseudomonas
  • casious: TB
  • serous: healthy healing ulcer
31
Q

What are the causes of tender ulcers?

A
  • ischemic ulcer
  • venous ulcer
  • any inflamed or infected ulcer
32
Q

What are the causes of non tender ulcers?

A

non-infected ulcers

  • neuropathic
  • malignant
  • TB
  • syphilitic
33
Q

Why is the base tested?

A
  • for presence of induration (underlying fibrosis)

most of chronic ulcers are indurated especially venous & malignant ulcers

34
Q

describe an ischemic ulcer.

A

vascular insufficiency causing sloughing of ischemic tissues

  • at most distal parts like toes, dorsum of foot, or around maleoli
  • pale or blackened or mummified margins
  • extremely tender
35
Q

describe a venous ulcer.

A

incompetent lower perforators leading to deposition of hemosiderin & release of proteolytic enzymes

  • first sign is itching & eczema
  • usually in Gaiter’s area
  • margin is pigmented & contains eczema
  • extremely tender
36
Q

describe a neuropathic ulcer.

A

shin denervation (autonomic neuropathy) -> trophic ulcer

  • at pressure sites or any friction site (ball of toes & heel)
  • hypertrophied skin (hyperkeratotic) margin
  • not tender unless there’s an infection

Surgery M4 part 1 (47 decks)

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