Lecture 6 - Neuropathic Ulcers

Question 1

what is a common characteristic of diabetic ulcer periwound?

Answer 1

callous around the wound bed

Question 2

characteristics of the neuropathic ulcer periwound

Answer 2

• callous
• thickened toenails
• edema, if autonomic neuropathy
• microvascular changes
• warm or cool

Question 3

when the body does not have enough glucose for energy, burns fats instead, resulting in a build up of acids

Answer 3

ketosis

Question 4

risk factors for T2 DM in childhood

Answer 4

> 85% body weight for age/sex
120% ideal weight
relative w DM
high risk ethnicity
mother w gestational DM

Question 5

how does DM relate to neuropathic ulcers

Answer 5

hyperglycemia -> more glucose -> more sorbitol made -> more damage

Question 6

how does high glucose lead to tissue damage

Answer 6

glucose will bind to proteins= glycosylated proteins
these cause tissue damage and form free radicals

Question 7

sorbitol results from what?

Answer 7

breakdown of glucose

Question 8

neuropathic ulcer risk factors

Answer 8

• vascular disease
• neuropathy
• mechanical stress
• impaired healing
• poor vision
• inadequate care and patient education!

Question 9

is neuropathic ulcers a micro or macro vascular disease?

Answer 9

microvascular- below the knee

Question 10

macrovascular diseases, with regards to ulcers, are usually where?

Answer 10

above the knee

Question 11

DM causing thickening of _________ ________, leading to decreased ___

Answer 11

thickening of basement membrane, decreased O2 and nutrients

Question 12

3 types of neuropathy

Answer 12

sensory, motor, autonomic

Question 13

what is the most common complication of DM T2

Answer 13

neuropathy

Question 14

inability to accurately perceive trauma to an affected area, usually no idea of loss

Answer 14

sensory neuropathy

Question 15

paralysis of the intrinsic muscles

Answer 15

motor neuropathy

Question 16

motor neuropathy in the feet:
___________ plantar pressure
_________ sheer forces
_________ stability in stance
hallux _______
claw toe deformity

Answer 16

increased plantar pressure
increased shear forces
decreased stability in stance
hallux valgus
claw toe deformity

Question 17

motor neuropathy in the hand:
__________ grip
_______ fine motor
_________ injury
hand deformity

Answer 17

decreased grip
decreased fine motor
increased injury hand deformity

Question 18

autonomic neuropathy skin changes

Answer 18

sweating mechanisms (decreased) , callus formation (increased) , disturbed blood flow

large contributor to neuropathic ulcers!

Question 19

what leads to charcot foot?

Answer 19

shoving deformed foot into footwear that doesnt work anymore

uncontrolled vasodilation -> increased blood flow -> more Ca -> predisposed for fracture -> charcot foot

Question 20

will DM T2 patients always have an immune response with infection?

Answer 20

no

Question 21

hyperglycemia:
______ collagen synthesis, phagocytosis, angiogenesis, fibroblast proliferation
______ tensile strength

Answer 21

decrease collagen synthesis, phagocytosis, angiogenesis, fibroblast proliferation
reduced tensile strength

Question 22

an ulcer that is larger, deeper, or older will take ____ to heal

Answer 22

longer

Question 23

midfoot ulcerations heal _______ than forefoot

Answer 23

midfoot ulceration heal faster than forefoot

Question 24

fasting glucose versus A1C

Answer 24

fasting- snapshot, fast for 12 hours beforehand
A1C- aggregate of how they have managed glucose over the past 3 months.

Question 25

review (idk if this will be on the test)

Answer 25

Question 26

what are tests to assess circulation?

Answer 26

capillary refill, doppler US, ABI, TBI, arteriography, transcutaneous O2 measurement

Question 27

tests to assess sensory integrity

Answer 27

monofilament test
1st, 3rd, 5th digit
12t, 3rd, 5th met heads
medial and lateral midfoot
calcaneus

test each 3 times

Question 28

for local neuropathic ulcer wound care, should the callus be removed?

Answer 28

yes- must be removed

Question 29

for local neuropathic ulcer wound care, do you moisturize in between toes?

Answer 29

no!
you moisturize the periwound, but not between toes

Question 30

wagner scale/ UT scale is for

Answer 30

grading neuropathic ulcers

Question 31

will calluses heal?

Answer 31

no

Question 32

what is the gold standard of care for neuropathic ulcers

Answer 32

total contact casting

Question 33

benefits of TCC

Answer 33

off loads ulcer by spreading pressure, helps with edema management, decreased shear and protects

Question 34

contraindications of TCC

Answer 34

non compliance, infection, edema fluctuations
ABI <0.45

Question 35

what does gait and mobility help with for neuropathic ulcers?

Answer 35

mobilize while safely eliminate pressure on the ulcer

Question 36

what does ROM exercise help with neuropathic ulcers

Answer 36

limitations in ROM can increase pressure, addresses this issue

Question 37

aerobic exercise can help with what in neuropathic ulcers

Answer 37

glycemic control, help patient to understand ways to do this without walking

Question 38

good glycemic control can reduce DM complications:
__% decrease in microvascular complications
__% reduction in amputations

Answer 38

25% decrease in complications
36% reduction in amputations

Question 39

surgeries for neuropathic ulcers

Answer 39

• surgical debridement
• incision and drainage (abscesses)
• address foot deformities (decrease pressure points)
• amputation

Question 40

with infection there is a ___ x increased risk of amputation

Answer 40

154 x

Question 41

does medicare cover footwear?

Answer 41

yes- if patients have documented lack of protective sensation qualify for 2 pairs of DM shoes