Foot Ulcer Flashcards
DDx for this ulcer
Malignancy (melanoma, SCC)
Vasculitis
Dermatological condition: pyoderma granulosum
Infectious: Hansen’s disease, syphilis, deep seated infection, osteomyelitis
DM
Trauma: chemical, thermal, pysical
PVD
Venous insufficiency
What factors contribute to ulceration in DM?
Loss of pressure and pain sensation
Dry skin
Reduced joint mobility
Structural deformity
Poor balance and instability
How can ulcers be treated initially?
Treat any cellulitis with IV Abx
Surgical debridement
Trial of maggot therapy
What are the 5 essential components to clinically assess, Ix and manage in order to treat and prevent recurrence of diabetic foot complications?
Peripheral neuropathy
PVD
Ulceration
Infection
Maximise diabetes control
What measures can be taken in an attempt to prevent the formation of pressure ulcers during admission of neuropathic patients?
Pressure off-loading with air mattress
Orthotics (in order of efficacy): CAM walker, total contact cast, half shoe
What is the Ix of choice for diabetes-related critical limb ischaemia (evidence of ulceration or gangrene)? What other Ix can be performed? What Mx is indicated?
Angiography
Ix: duplex U/S, toe pressures (less than 45mmHg indicates ulcer is unlikely to heal), transcutaneous O2 (less than 30mmHg indicates ulcer is unlikely to heal)
Mx: determine suitability for PTA, bypass
What are the clinical signs of an infected ulcer?
Purulent discharge (pus)
Two or more: pain/tenderness, swelling, redness, warmth
What clinical signs suggest osteomyelitis?
Prolonged ulcer duration
Recurrence of ulceration at same site
Can occur post-surgical intervention
“Sausage toe”: toe swollen with non-pitting oedema, uerythematous, obliteration of contours
Probes to bone or bone on show
What serological markers of infection raise with a severely infected ulcer?
RBG
WCC
ESR
CRP
What biochemical markers may suggest osteomyelitis?
ALP
Prevalence of osteomyelitis increases with ESR (100% of patients with ESR >70mm/hr had osteomyelitis with no signs of infection on examination)
How can osteomyelitis can be diagnosed radiologically?
XR (but time delay for changes to appear)
Tc99 bone scan: more sensitive but non-specific
WBC scans: higher specificity but less sensitive than Tc99
MRI: most useful for making Dx and defining extent of infection
How should a bone biopsy be obtained in the setting of osteomyelitis?
Obtained through uninfected skin
If able, discontinue Abx for 48 hrs prior
Send off sample for histopathology and MCS to guide Abx use (improves outcomes)
Wound Mx TIME principle
Tissue non viable: remove defective tissue (sharp/autolytic/larval)
Inflammation or infection: remove or reduce bacterial load
Moisture imbalance: restore
Edge of wound not advancing: address T/I/M issues
What treatment is indicated for a diabetic ulcer with underlying osteomyelitis with # of fibula at ankle joint?
BKA
Rehabilitation
What is the role of amputee rehab?
Return a person to maximal physical, psychological, social and vocational function
Minimise disability and handicap
Improve prosthetic (artificial limb) acquisition
What are the 7 phases of amputee rehabilitation?
Pre-operative
Acute post-surgical
Pre-prosthetic
Prosthetic design
Prosthetic gait training
Community integration
Follow-up
What aspects of amputee rehabilitation begin pre-operatively?
Pre-op consultation with rehab specialist to discuss:
Amputation level
Functional expectations
Rehabilitation processes and timeframes
Suitability for prosthesis
Phantom limb pain (PLP) and sensation
What 4 factors influence prosthetic acquisition following amputation?
Physical fitness
Fewer comorbidities
Ability to stand on remaining leg
Motivated to walk
What % of diabetic amputees have a contralateral amputation within 2-5 years?
50%
And within 2 years, 15% transtibial amputations are converted to transfemoral and 30% of patients are dead
What is phantom limb pain (PLP)? What factors can aggravate it and what treatments are used to manage it?
Pain sensation localising to missing extremity or body part; variable in severity and subject description, onset usually within a week
Aggravated by local factors e.g. wound infection, general medical problems
Mx: medication, physical modalities (massage, TENS), psychological (distraction)
What is phantom limb sensation (PLS) and why is it important?
Any sensation in absent limb except pain
Can contribute to falls
What are the goals of inpatient rehabilitation post-amputation?
Wound healing
Residual limb (“stump”) care
Pain Mx
Thrombo-embolism prophylaxis
Establish bowel and bladder program
Care of other foot, joint preservation
Mx of co-morbidities (e.g. IHD)
Optimisation of CV RFs
Goals: walking independently, able to mobilise around home as needed (including upstairs if relevant), preventing or reversing deconditioning after prolonged immobility, minimising falls risk, ensuring independent with ADLs, providing education and emotional support
Who is involved in the amputee rehabilitation team?
Prosthetist and orthotist
OT
Physio
Nurse and wound nurse
Surgeon
Endocrinologist
Dietician
Psychologist
Diabetes educator
SW
Podiatrist
Rehab physician
Patient and family!
What is an RRD and what does it do?
Removable rigid dressing
Fitted by prosthetist to reduce oedema, protect stump from trauma and decrease pain
