Lecture 6 - Neuropathic Ulcers Flashcards
what is a common characteristic of diabetic ulcer periwound?
callous around the wound bed
characteristics of the neuropathic ulcer periwound
- callous
- thickened toenails
- edema, if autonomic neuropathy
- microvascular changes
- warm or cool
when the body does not have enough glucose for energy, burns fats instead, resulting in a build up of acids
ketosis
risk factors for T2 DM in childhood
> 85% body weight for age/sex
120% ideal weight
relative w DM
high risk ethnicity
mother w gestational DM
how does DM relate to neuropathic ulcers
hyperglycemia -> more glucose -> more sorbitol made -> more damage
how does high glucose lead to tissue damage
glucose will bind to proteins= glycosylated proteins
these cause tissue damage and form free radicals
sorbitol results from what?
breakdown of glucose
neuropathic ulcer risk factors
- vascular disease
- neuropathy
- mechanical stress
- impaired healing
- poor vision
- inadequate care and patient education!
is neuropathic ulcers a micro or macro vascular disease?
microvascular- below the knee
macrovascular diseases, with regards to ulcers, are usually where?
above the knee
DM causing thickening of _________ ________, leading to decreased ___
thickening of basement membrane, decreased O2 and nutrients
3 types of neuropathy
sensory, motor, autonomic
what is the most common complication of DM T2
neuropathy
inability to accurately perceive trauma to an affected area, usually no idea of loss
sensory neuropathy
paralysis of the intrinsic muscles
motor neuropathy
motor neuropathy in the feet:
___________ plantar pressure
_________ sheer forces
_________ stability in stance
hallux _______
claw toe deformity
increased plantar pressure
increased shear forces
decreased stability in stance
hallux valgus
claw toe deformity
motor neuropathy in the hand:
__________ grip
_______ fine motor
_________ injury
hand deformity
decreased grip
decreased fine motor
increased injury hand deformity
autonomic neuropathy skin changes
sweating mechanisms (decreased) , callus formation (increased) , disturbed blood flow
large contributor to neuropathic ulcers!
what leads to charcot foot?
shoving deformed foot into footwear that doesnt work anymore
uncontrolled vasodilation -> increased blood flow -> more Ca -> predisposed for fracture -> charcot foot
will DM T2 patients always have an immune response with infection?
no
hyperglycemia:
______ collagen synthesis, phagocytosis, angiogenesis, fibroblast proliferation
______ tensile strength
decrease collagen synthesis, phagocytosis, angiogenesis, fibroblast proliferation
reduced tensile strength
an ulcer that is larger, deeper, or older will take ____ to heal
longer
midfoot ulcerations heal _______ than forefoot
midfoot ulceration heal faster than forefoot
fasting glucose versus A1C
fasting- snapshot, fast for 12 hours beforehand
A1C- aggregate of how they have managed glucose over the past 3 months.
review (idk if this will be on the test)
what are tests to assess circulation?
capillary refill, doppler US, ABI, TBI, arteriography, transcutaneous O2 measurement
tests to assess sensory integrity
monofilament test
1st, 3rd, 5th digit
12t, 3rd, 5th met heads
medial and lateral midfoot
calcaneus
test each 3 times
for local neuropathic ulcer wound care, should the callus be removed?
yes- must be removed
for local neuropathic ulcer wound care, do you moisturize in between toes?
no!
you moisturize the periwound, but not between toes
wagner scale/ UT scale is for
grading neuropathic ulcers
will calluses heal?
no
what is the gold standard of care for neuropathic ulcers
total contact casting
benefits of TCC
off loads ulcer by spreading pressure, helps with edema management, decreased shear and protects
contraindications of TCC
non compliance, infection, edema fluctuations
ABI <0.45
what does gait and mobility help with for neuropathic ulcers?
mobilize while safely eliminate pressure on the ulcer
what does ROM exercise help with neuropathic ulcers
limitations in ROM can increase pressure, addresses this issue
aerobic exercise can help with what in neuropathic ulcers
glycemic control, help patient to understand ways to do this without walking
good glycemic control can reduce DM complications:
__% decrease in microvascular complications
__% reduction in amputations
25% decrease in complications
36% reduction in amputations
surgeries for neuropathic ulcers
- surgical debridement
- incision and drainage (abscesses)
- address foot deformities (decrease pressure points)
- amputation
with infection there is a ___ x increased risk of amputation
154 x
does medicare cover footwear?
yes- if patients have documented lack of protective sensation qualify for 2 pairs of DM shoes
