Foot ulcers Flashcards
What is the pathophysiology of diabetes related foot wounds?
Involves 5 aspects
1. Neuropathy (main):
Type 1 DM>20 yrs: >40%
Type 2 DM: 10% at Diagnosis, 50% at 20yrs
8-18x risk of ulceration
2-15x risk of amputation
- loss pressure/pain sensation, dry skin, reduced joint mobility, structural deformity, poor balance and instability
- Trauma
- Deformity
- Infection
- PVD
What is the multidisciplinary treatment plan to treat diabetes related foot wounds?
A multidisciplinary team, working on interdisciplinary goals, set together with patient and family.
- Dietician
- Psychologist
- Diabetes educator
- Social worker
- Podiatrist
- Rehab physician
- Prosthetist orthotist
- Occupational therapist
- Physiotherapist
- Nurse, wound nurse
- Surgeon, endocrinologist
What are the major causes and precipitating factors for limb amputation?
- Diabetes foot infection/gangrene/ulcers
- Poor circulation due to peripheral arterial disease (damage/narrowing of arteries)
50% of the diabetic amputees have a contralateral amputation within 2-5 years
why can early referral promote successful rehabilitation and why is it important to set goals in
rehabilitation?
For medical, functinoal & educational/emotional support
Medical: •Wound healing •Residual limb (‘stump’) care •Pain management •Thrombo-embolism prophylaxis •Establish bowel and bladder program •Care of the other foot, joint preservation •Management of co-morbidities (IHD) •Optimize cardiovascular disease risk factors
Mobility & functional:
•‘not safe for discharge home’
•Unable to walk independently, and the bedroom at home is upstairs
•Deconditioned, having spent past 8 weeks in a hospital bed
•Falls risk
•Needs help for showering and dressing
outline components of a rehabilitation program following limb loss
- ‘Return a person to maximal physical, psychological, social and vocational function’*
- Minimise disability and handicap
- Improve prosthetic (artificial limb) acquisition
What are the possible causes of a foot ulcer?
- Peripheral artery disease
- venous insufficiency
- diabetes
- infectious (Hansen’s disease, Syphilis, Deep seated infection; osteomyelitis)
- Trauma (chemical, thermal, physical)
- Dermatological condition (pyoderma granulosum)
- Malignancy (melanoma, SCC)
- Vasculitis
Describe diabetes-related foot ulcers
•25% will develop a foot complication
–~25% will develop a foot infection
–20-60% of ulcers have underlying osteomyelitis
–Ulcer recurrence: 34% / year, 70% over 5yrs
- Foot disease is the commonest reason for hospitalisation
- Diabetes commonest reason for amputations (& still increasing)
- 25-50% of costs related to inpatient diabetes care directly attributable to foot pathology
How can you Ix & assess peripheral arterial disease?
Imaging, PTCA, Bypass
Angiography: Investigation of choice for diabetes related
Critical Limb Ischaemia (ulceration or gangrene)
–Determine suitability for PTA, Bypass
–Duplex Ultrasound
–Toe pressures (
How do you clinically assess ulceration & infection?
•Infection: Clinical diagnosis
–Purulent discharge (pus)
–Or two or more of: pain/tenderness, swelling, redness, warmth
•Osteomyelitis
–Ulcer duration, but how long?
–Recurrence of ulceration at the same site
–Post surgical intervention
–“sausage toe” : toe swollen with non pitting oedema, erythematous, obliteration of contours
–Probe to bone or bone on show
How do you investigate for ulceration & infection?
•Serological Markers of Infection
–Conflicting data for population with diabetes
–RBG, WCC, ESR, CRP tend to increase with severe infections
•Alkaline Phosphatase
–Rising Alk Phos associated with osteomyelitis (p=0.06)
–100% of patients with Alk Phos >135 IU/L had osteomyelitis
•ESR
(1) Prevalence of OM increased as ESR increased (p=0.003)
–100% of patients with ESR >70mm/h had OM with no signs of infection on examination
(2) Retrospective chart review
–ESR>70mm/h = OM (sens 89.5%, spec 100%)
How do you radiologically Dx osteomyelitis?
•MRI
–Most useful: making diagnosis and defining extent of infection
•X-ray
–Time delay for changes to appear
•Tc99 bone scan
–More sensitive than plain x-ray
–Non-specific
•WBC scans
–Higher specificity than Tc99 scan but less sensitive
How do you Dx osteomyelitis?
Bone Biopsy
•Obtained through uninfected skin
•If able - discontinue antibiotics for 48 h before
•Histopathology for diagnosis AND Micro for antibiotic therapy
•Guide antibiotic use
–French study 30% more patients free of infection at 12 months if guided by bone biopsy
Describe Wound management Time principle
TIME
- Tissue non viable: Remove defective tissue (sharp/autolytic/larval)
- Inflammation or infection: Remove or reduce bacterial load
- Moisture imbalance: Restore moisture balance
- Edge of wound not advancing: Address T/I/M issues
What is phantom limb pain?
- Pain sensation localizing to a missing extremity or body part
- Common (30-81%)
- Variable in severity and subjective description
- Onset is usually within a week
- Aggravated by local factors such as wound infection and general medical problems.
- Response to treatment varies.
Rx e.g.
- Medication
- Physical modalities – massage, TENS
- Psycholoqgical – distraction
What is phantom limb sensation?
- Any sensation in the absent limb except pain
- Common
- Can contribute to falls
