Foot Ulcer Flashcards
What are some causes of foot ulcers?
Vasculitis Trauma Peripheral arterial disease Venous insufficiency Diabetes Infectious Dermatological condition Malignancy
What proportion of people with diabetes will develop a foot complication?
25%
What is the commonest reason for hospitalisation in diabetes?
Foot disease
What is the commonest reason for amputations?
Diabetes
What factors in diabetes lead to lower limb ulceration?
Neuropathy
Trauma
Deformity
What are the clinical features of neuropathy?
Loss of pressure/pain sensation Dry skin Reduced joint mobility Structural deformity Poor balance Instability
What are the essential components to clinically assess, investigate, and manage, in order to treat and prevent recurrence of diabetic foot complications?
Peripheral neuropathy Peripheral vascular disease Ulceration Infection Maximise diabetes control
What is the investigation of choice for diabetes-related critical limb ischaemia?
Angiography
What other investigations can be used to investigate peripheral vascular disease?
Duplex ultrasound
Toe pressures
Transcutaneous oxygen
How is infection diagnosed in ulcers?
Clinical diagnosis Purulent discharge Or 2+ of - Pain/tenderness - Swelling - Redness - Warmth
How can the presence of osteomyelitis in an ulcer be determined?
Ulcer duration Recurrence of ulcer at same site Post-surgical intervention Sausage toe = toe swollen with non-pitting oedema, erythema, and obliteration of contours Probe to bone/bone on show
What are the serological markers of infection?
Increase with severe infection
- Random blood glucose
- WCC
- ESR
- CRP
What is the association between alkaline phosphatase and osteomyelitis?
Rising ALP associated with osteomyelitis
How can osteomyelitis be diagnosed using imaging?
X-ray - time delay for changes to appear
Tc99 bone scan
- More sensitive than plain x-ray
- Non-specific
WBC scan - higher specificity than Tc99 scan but less sensitive
MRI - most useful in making diagnosis and defining extent of infection
What does obtaining a bone biopsy to diagnose osteomyelitis involve?
Obtained through uninfected skin
If able, discontinue Abx for 48 hours before
Histopathology for diagnosis
Microbiology for specific Abx therapy
What is the TIME principle in wound management?
T = tissue non-viable > remove defective tissue I = inflammation/infection > remove/reduce bacterial load M = moisture imbalance > restore E = edge of wound not advancing > address T/I/M issues
What is the role of amputee rehabilitation?
Return person to maximal physical, psychological, social, and vocational function
Minimise disability and handicap
Improve prosthetic acquisition
How can the foot claw in neuropathy?
Motor neuropathy > 1st set of nerves to go
Supply intrinsic muscles of feet
Larger, more proximal muscles overpower small muscles of foot > clawing of foot
Why do people get dry feet in diabetic neuropathy?
Autonomic nerves become damaged > decreased innervation of sweat glands
What does an examination of someone with possible neuropathy involve?
Watch way they walk
Are they looking at ground because of neuropathy?
If very vasculitic, can get cellulitis in foot - hot and swollen
- Poor vascular supply
- Decreased immune ability due to chronic disease
Pulses important to measure - gauge of macrovascular disease
Always look for signs of peripheral vascular disease
What investigations are of use in peripheral vascular disease?
Ankle-brachial index not as useful anymore - absolute toe pressure considered more accurate now
- <45 mmHg - outright ischaemia
- Gauge of microvascular disease
How does a handheld doppler ultrasound determine the presence of vascular disease?
Number of sounds - Triphasic doppler - normal - Even 4 sounds normal - Biphasic indicates element of calcification - Monophasic indicates severe calcification Flow - Dampened - Pulsatile
How do you know if a wound is healing properly?
50% reduction in 4 weeks
What is the management of a foot ulcer?
SNAP Daily foot checks Measured, appropriate footwear Referral to multidisciplinary teams - Podiatry - Orthotist Avoid pressure ulcers - Avoid tight covers - Use air/foam mattress Offload pressure when walking - Total contact cast - works best as patient wears it all the time - Cam walker - Half shoe Osteomyelitis - 6 week course of Abx - Repeat x-ray/other scan
When should amputation be considered?
Severe systemic disease
