Foot Wound Exam And Tx Flashcards
Basic neuro test
Wagner and Semmes weinstein monofilament 5.07/10g
Intact means 7/10
If monofilament shows intact
Proceed w/ 128 hz tuning fork
If monofilament not intact
Precede w/ cotton ball
Foot vascular testing - ABI TBI and pulses w/ handheld Doppler
Dorsalis pedis
Posterior tibial
Lateral calcaneal
Foot- further arterial tests
Segmental perfume pressure (useful for falsely elevated ABI in some person w/ DM
Lower extremity arterial duplex ultrasound
Foot deformities
Charcot foot Hammer toe (pip) claw toe (pip plus dip) mallet toe (dip)
Wound severity
Wagner ulcer classification system
University of Texas diabetic wound classification
Pressure ulcer staging
Venous ulcer locations
Above medial malleolus
Above lateral malleolus
Arterial ulcer location
Over toe joints
Anterior shin
Under heel
Over malleoli
Neuropathic ulcer location
Over toe joints Under met head Under heel Over malleoli Inner side of first met head Planar surface of foot
Predisposition to neuropathic ulcers
Diabetes
SCI
AIDS
Peripheral neuropathy
Would characteristics of neuropathic ulcer
Well defined margins Calloused periwound Deep wound bed Cellulitis and/or osteomyelitis Granulation tissue
3 types of neuropathy changes
Diminished or absent sensation in foot
Xerox is and anhydrous is
Musculoskeletal changes leading to foot deformities
Neuropathic ulcer - presentation
3 types of neuropathy changes
Subcutaneous fat atrophy
Arterial findings if pt has PVD
Wagner ulcer classification system
Used as a predictor of outcome: increased amputation risk or prolonged ulcer healing time
Wagner ulcer classification grade 0
No open lesions
May have deformity or cellulitis
Wagner ulcer classification grade 1
Superficial diabetic ulcer
Partial or full thickness
Wagner ulcer classification grade 2
Ulcer extension to ligament, tendon, joint capsule, or deep fascia w/out abscess or osteomyelitis
Wagner ulcer classification grade 3
Deep ulcer w/ abscess, osteomyelitis, or joint sepsis
Wagner ulcer classification grade 4
Gangrene localized to portion of forefoot or heel
Wagner ulcer classification grade 5
Extensive gangrenous involvement of the entire foot
University of Texas diabetic wound classification
Graded by depth then staged
UT grades
0 - epithelialized wound
1 - superficial wound
2- wound penetrates to tendon or capsule
3 - wound penetrates to bone or joint
UT stages
A - no infection or ischemia
B - infection present
C- ischemia present
D - infection and ischemia present
TX foot ulcer
Offloading!!!
Properly fitting footwear
Protection from trauma and pressure
If diabetic, management of blood glucose, A1c level every 6 mo
total contact cast
Gold standard for offloading neuropathic foot ulcers
Irremovable cast walker
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
Removeable cast walker
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
Half shoe
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
Football dressing
Layered padding applied to foot to reduce forefoot pressure and sheer
Difficult for pts to remove
Small retrospective study
Felted foam
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
Offloading/healing shoe
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
Offloading continuum
- 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
Types of traumatic wounds
Contusion Abrasion Laceration Bite Puncture Impalement Avulsion/degloving Crush injury Burn Post surgical
Treat foot trauma
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
Surgical side infection - treat the cause
- 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
Pressure injury - treat cause
- 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
Arterial ulcers - tx the cause
- 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.
No debridement for
Stable, dry eschar unless ordered by vascular surgeon
Infection tx
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
ABI screens for
Arterial insufficiency
Safe level of compression
Wound healability
Ab 0.8-1.2
30-40 mmHG
Compression
ABI 0.6-0.8
20-30 mmHG
Compression w/ caution
ABI <0.6
No compression
Venous ulcer- predisposition
- 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
3 common components of venous disease
Valve incompetence causing reflux
Venous obstruction
Calf muscle weakness causing insufficient venous return
Typical VLU presentation
- Located in gaiter area
- Wound w/ red granulation tissue and/or cellular -debris or crust
- Irregular wound margins
- Periwound skin color changes
Venous - leg appearance
- firm edema
- dilated superficial veins
- Dry, thin scaly skin
- evidence of healed ulcers
- leg hyperpigmentation
Venous - periwound appearance
Leg edema -Dermatitis -Maceration v Hyperkeratotic tissue -Atrophie blanche (white, thin w/red vessels) -Lipodermatosclerosis (bound down, hyperpigmented or hypopigmented)
Venous wound appearance
- granulation tissue
- fibrin
- slough
- crusted areas
- non granular tissue
- irregular wound margins
- superficial wound
- min to mod pain
- mod to heavy exudate
Venous - to cause
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
Slow healing
<40% area decrease in 1 month
Arterial - predisposing factors
PVD Smoking DM Advanced age Male gender Hypertension
Arterial - leg appearance
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
Arterial location
B/n toes Tip of toes Pressure points Sites of trauma/footwear rubbing Typically distal to ankle
Arterial wound characteristics
Well - defined wound margins Pale or necrotic wound bed Gangrene may be present Minimal exudate Painful Infection common Planched or purpuric periwound
Tx cause of arterial
ABI
If <0/8, arterial US and ask for vascular sx consult
**gangrene in outpt/non acute:
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
Arterial tx
Protect area
Apply non occlusive dressing if needed
Cautious debridement only after basic vascular testing done w/ results eval
Types of traumatic wounds
Contusion Abrasion Laceration Bite Puncture Impalement Avulsion/degloving Crush injury Burn Post-sx
