Foot Wound Exam And Tx

Question 1

Basic neuro test

Answer 1

Wagner and Semmes weinstein monofilament 5.07/10g

Intact means 7/10

Question 2

If monofilament shows intact

Answer 2

Proceed w/ 128 hz tuning fork

Question 3

If monofilament not intact

Answer 3

Precede w/ cotton ball

Question 4

Foot vascular testing - ABI TBI and pulses w/ handheld Doppler

Answer 4

Dorsalis pedis
Posterior tibial
Lateral calcaneal

Question 5

Foot- further arterial tests

Answer 5

Segmental perfume pressure (useful for falsely elevated ABI in some person w/ DM
Lower extremity arterial duplex ultrasound

Question 6

Foot deformities

Answer 6

Charcot foot
Hammer toe (pip)
claw toe (pip plus dip)
mallet toe (dip)

Question 7

Wound severity

Answer 7

Wagner ulcer classification system
University of Texas diabetic wound classification
Pressure ulcer staging

Question 8

Venous ulcer locations

Answer 8

Above medial malleolus

Above lateral malleolus

Question 9

Arterial ulcer location

Answer 9

Over toe joints
Anterior shin
Under heel
Over malleoli

Question 10

Neuropathic ulcer location

Answer 10

Over toe joints
Under met head
Under heel
Over malleoli
Inner side of first met head
Planar surface of foot

Question 11

Predisposition to neuropathic ulcers

Answer 11

Diabetes
SCI
AIDS
Peripheral neuropathy

Question 12

Would characteristics of neuropathic ulcer

Answer 12

Well defined margins
Calloused periwound
Deep wound bed
Cellulitis and/or osteomyelitis
Granulation tissue

Question 13

3 types of neuropathy changes

Answer 13

Diminished or absent sensation in foot
Xerox is and anhydrous is
Musculoskeletal changes leading to foot deformities

Question 14

Neuropathic ulcer - presentation

Answer 14

3 types of neuropathy changes
Subcutaneous fat atrophy
Arterial findings if pt has PVD

Question 15

Wagner ulcer classification system

Answer 15

Used as a predictor of outcome: increased amputation risk or prolonged ulcer healing time

Question 16

Wagner ulcer classification grade 0

Answer 16

No open lesions

May have deformity or cellulitis

Question 17

Wagner ulcer classification grade 1

Answer 17

Superficial diabetic ulcer

Partial or full thickness

Question 18

Wagner ulcer classification grade 2

Answer 18

Ulcer extension to ligament, tendon, joint capsule, or deep fascia w/out abscess or osteomyelitis

Question 19

Wagner ulcer classification grade 3

Answer 19

Deep ulcer w/ abscess, osteomyelitis, or joint sepsis

Question 20

Wagner ulcer classification grade 4

Answer 20

Gangrene localized to portion of forefoot or heel

Question 21

Wagner ulcer classification grade 5

Answer 21

Extensive gangrenous involvement of the entire foot

Question 22

University of Texas diabetic wound classification

Answer 22

Graded by depth then staged

Question 23

UT grades

Answer 23

0 - epithelialized wound
1 - superficial wound
2- wound penetrates to tendon or capsule
3 - wound penetrates to bone or joint

Question 24

UT stages

Answer 24

A - no infection or ischemia
B - infection present
C- ischemia present
D - infection and ischemia present

Question 25

TX foot ulcer

Answer 25

Offloading!!! Properly fitting footwear Protection from trauma and pressure If diabetic, management of blood glucose, A1c level every 6 mo

Question 26

total contact cast

Answer 26

Gold standard for offloading neuropathic foot ulcers

Question 27

Irremovable cast walker

Answer 27

Removeable cast walker w/ foam insole rendered irremovable by circumferential fiberglass casting strip Similar results to TCC, forced adherence, lower material and application cost, faster to apply

Question 28

Removeable cast walker

Answer 28

Cast walker, foam insole w/ removeable pegs Mean peak pressure similar to TCC Pt able to remove device 65% healed at 12 weeks compared to 89.5% w/ TCC

Question 29

Half shoe

Answer 29

Available w/ forefoot or heel relief May be unstable for pts w/ balance or strength impairments Optional: add padding Higher mean peak plantar pressures than TCC and RCW Lower mean peak plantar pressures than felted foam w/ post op shoe 58.3% healed

Question 30

Football dressing

Answer 30

Layered padding applied to foot to reduce forefoot pressure and sheer Difficult for pts to remove Small retrospective study

Question 31

Felted foam

Answer 31

Felt/foam combo to entire plantar surface, cutout for wound, open to side of foot, beveled edges Reduced pressure at planted wound 297–>90 kPA No longer effective at day 4

Question 32

Offloading/healing shoe

Answer 32

Protective shoe w/ foam insole Rigid sole limits MP ext, dispersing pressure over plantar surface during gait Removeable insole pegs may reduce pressure at wound

Question 33

Offloading continuum

Answer 33

- Start w/ TCC, offloading boot, custom multilayer orthosis - when wound closes, progress to lesser offloading device for 2-3 was - wean off and into diabetic shoe w/ custom mold insert

Question 34

Types of traumatic wounds

Answer 34

``` Contusion Abrasion Laceration Bite Puncture Impalement Avulsion/degloving Crush injury Burn Post surgical ```

Question 35

Treat foot trauma

Answer 35

Protect area from further trauma Protect area from water, dirt; keep covered in shower/bath Evaluate footwear and correct as needed Remind pt to wear shoes ALL THE TIME w/ open wound

Question 36

Surgical side infection - treat the cause

Answer 36

- Communicate w/ physician if infection is not controlled - check for remaining sutures causing irritation or stitch abscess. Get clearance from surgeon to remove - check for factors causing trauma - control edema

Question 37

Pressure injury - treat cause

Answer 37

- help neurons educate and position at risk pts - turn every 2 hours or less - keep pts off of existing pressure injuries - increase mobility and independence of patients asap - monitor skin closely during tx - help w/ preventative measure and support surface adherence

Question 38

Arterial ulcers - tx the cause

Answer 38

- ABI - arterial ultrasound if ABO <0.8. Ask for vascular surgery consult - gangrene in outpatient or non-acute—> referral to vascular surgeon, be in communication w/ primary MD and document!! May need to be seen in ER if moist/worsening - protect area - apply non-occlusive dressing - cautious debridement, only after basic vascular testing.

Question 39

No debridement for

Answer 39

Stable, dry eschar unless ordered by vascular surgeon

Question 40

Infection tx

Answer 40

``` Call MD to report status of wound if -pt not on PO or IV antibiotics -has been on PO or IV abx 3-4+ days and not improving Consider having pt evaled by MD Document your comm w/ MD ```

Question 41

ABI screens for

Answer 41

Arterial insufficiency Safe level of compression Wound healability

Question 42

Ab 0.8-1.2

Answer 42

30-40 mmHG | Compression

Question 43

ABI 0.6-0.8

Answer 43

20-30 mmHG | Compression w/ caution

Question 44

ABI <0.6

Answer 44

No compression

Question 45

Venous ulcer- predisposition

Answer 45

- venous valve incompetence - varicose veins - hx of ulcers - DVT - leg trauma - hx of LE surgeries - LE weak - impaired ankle motion or limited mobility - advanced age - medication - smoking - obesity - mult pregnancies

Question 46

3 common components of venous disease

Answer 46

Valve incompetence causing reflux Venous obstruction Calf muscle weakness causing insufficient venous return

Question 47

Typical VLU presentation

Answer 47

- Located in gaiter area - Wound w/ red granulation tissue and/or cellular -debris or crust - Irregular wound margins - Periwound skin color changes

Question 48

Venous - leg appearance

Answer 48

- firm edema - dilated superficial veins - Dry, thin scaly skin - evidence of healed ulcers - leg hyperpigmentation

Question 49

Venous - periwound appearance

Answer 49

``` Leg edema -Dermatitis -Maceration v  Hyperkeratotic tissue -Atrophie blanche (white, thin w/red vessels) -Lipodermatosclerosis (bound down, hyperpigmented or hypopigmented) ```

Question 50

Venous wound appearance

Answer 50

- granulation tissue - fibrin - slough - crusted areas - non granular tissue - irregular wound margins - superficial wound - min to mod pain - mod to heavy exudate

Question 51

Venous - to cause

Answer 51

``` Compression wrapping or garments Exercise Elevation Education Pt buy in and participation Request venous US and referral to vascular surgeon inf slow healing, hx of recurrent venous leg ulcers ```

Question 52

Slow healing

Answer 52

<40% area decrease in 1 month

Question 53

Arterial - predisposing factors

Answer 53

``` PVD Smoking DM Advanced age Male gender Hypertension ```

Question 54

Arterial - leg appearance

Answer 54

``` Thin, Shiny, dry skin Hair loss on ankle and foot Dystrophic (thick) toenails Elevation pallor Dependent rubor Decreased temperature Absent or diminished pulses Cyanosis Ischemic pain ```

Question 55

Arterial location

Answer 55

``` B/n toes Tip of toes Pressure points Sites of trauma/footwear rubbing Typically distal to ankle ```

Question 56

Arterial wound characteristics

Answer 56

``` Well - defined wound margins Pale or necrotic wound bed Gangrene may be present Minimal exudate Painful Infection common Planched or purpuric periwound ```

Question 57

Tx cause of arterial

Answer 57

ABI | If <0/8, arterial US and ask for vascular sx consult

Question 58

**gangrene in outpt/non acute:

Answer 58

obtain urgent referral to vascular surgeon, be in comm / primary physician and document this. May need to be seen in ER if gangrene moist or worsening

Question 59

Arterial tx

Answer 59

Protect area Apply non occlusive dressing if needed Cautious debridement only after basic vascular testing done w/ results eval

Question 60

Types of traumatic wounds

Answer 60

``` Contusion Abrasion Laceration Bite Puncture Impalement Avulsion/degloving Crush injury Burn Post-sx ```