neuropathic ulcer Flashcards
difference in poly and peripheral neuropathy
peripheral - hands and feet
poly - multiple limbs
what % of individuals with diabetes get neuropathic ulcerations
25
A1c levels of significance
normal - <5.7
pre - 5.7 to 6.4
diabetes - >6.5
contraindications of blood glucose values and PT
200 mg/dL
which type of diabetes is the most prevalent
2
what is the hypothesis behind why hyperglycemia causes tissue damage
hemodynamic changes that increase microvascular pressure
glycosylation
accumulation of sorbitol
what is glycosylation
hyperglycemia causing glucose to bind to proteins passively
what is the timeframe for ulcer development in a patient diagnosed with diabetes
25 years on average
sequelae of neuropathy losses
sensation
motor
autonomic
what causes neuropathy
microcirculation inadequacies that lead to neural tissue ischemia and segmental demyelination
in those with neuropathy, what ulceration is most common
plantar ulceration
3.5x more
sensory neuropathy most affects one’s
protective sensations
- cannot detect irritation or trauma
motor neuropathy most affects one’s
intrinsic foot muscles
atrophy leading to hallux valgus and claw toe
foot deformities cause
abnormal shear forces on foot in the places not suited for them
- collapse of foot arch leads to ulcerations in the middle of the foot rather than heel or ball of foot
sequelae of autonomic neuropathy
locally and systemically
local disturbances in
sweating mechanism
callus formation
blood flow
systemically:
resting tachycardia
exercise intolerance
orthostatic hypotension
gastroparesis
explain how mechanical stress leads to NU and delayed healing
abnormal forces predispose individuals to ulceration
overload of pressure impairs tissue ability to repair
hyperglycemia’s affect on wound healing
decreased collagen synthesis, angiogenesis and fibroblast proliferation
tests that should be used in those with neuropathic ulcers
doppler ultrasound
ABI
capillary refill
sensory integrity
indications for ABI testing
plantar foot ulceration
decreased/absent pulses
s/s of arterial insufficiency
hx of PVD
hx of CAD
indications for capillary refill testing
digital ulcer
abnormal ABI
indications for sensory integrity testing
neuropathic ulcer
diabetes
plantar foot ulcer
neuro injury
ABI cut off for referral in NU assessment
<0.8
specifics of semmes weinstein monofilaments
closed eyes during testing
5.07 monofilament
avoiding callused areas
randomly test each location 3x
how to test sensation using tuning fork
128 Hz fork on first metatarsal head or malleolus
inability to perceive ___ monofilament indicates ____
4.17 = decreased sensation
5.07 = loss of protective sensation
6.1 = absent sensation
plantar locations for monofilament testing
pads of big toe, third and pinky
ball of foot
below third toe
below pinky toe
medial/lateral mid foot
heel pad
wagner classification grade
0 - no open lesion
1 - superficial ulcer
2 - deep ulcer to tendon, bone or capsule
3 - deep ulcer with abscess, osteomyelitis, joint sepsis
4 - localized gangrene
5 - gangrene of entire foot
most common positions of NU
plantar forefoot
first/second metatarsal heads
plantar heel
foot deformities and associated locations of ulceration
hallux rigidus = plantar big toe
rocker-bottom = midfoot
claw toe = dorsal aspect of toes
inappropriate footwear may cause an NU at
tips of toes
lateral aspect of 5th MTP
medial aspect of 1st MTP
posterior heel
wound presentation of NU
round, punched out
callused rim
minimal drainage
rarely eschar/necrotic material
what grade of wagner classification indicates amputation
3+
what education do we need to provide patients with NU
role of exercise
risk factor reduction
daily skin checks and care guidelines
when is total contact casting indicated
wagner score of 1/2
role of total contact casting
molded to foot and leg to allow for proper weight distribution
controls edema
protects from trauma/microorganisms
contraindications of total contact casting
osteomyelitis
gangrene
fluctuating edema
active infection
ABI <0.5
therapeutic exercises for those with NU
assess great toe extension
talocrural dorsiflexion
strengthening invertors and hip ER
aerobic exercise
what is diabetes categorized as a disease
disorder of carbohydrate, protein and fat metabolism due to changes in body’s ability to produce/ use insulin
main difference between type 1 and type 2 DM
1 - genetic, autoimmune disease, in ability to produce insulin
2 - develops over life, resistance to insulin
significant fasting blood glucose
normal = <100 mg/dL
prediabetes = 100-125 mg/dL
diabetes = >126 mg/dL
explain the relationship between peripheral artery disease and neuropathic ulcers
thickened basement membrane
- decreased O2 levels
- decreased nutrient delivery to tissue
what is diabetic neuropathic osetoarthropathy? what does it cause?
inflammatory phase characterized by foot edema, erythema, and increased temperature
bone and articular destruction
- progresses to multi-joint dislocation and fx
how to treat diabetic neuropathic osteoarthropathy
strict immobilization and limited weight bearing
what causes tissue failure
tissue breakdown rate exceeds tissue repair rate
how is the visual system affected by diabetes
retinopathy
glaucoma
cataracts
compare healing rates of forefoot ulcers and rearfoot ulcers
forefoot heal faster than rearfoot
what does A1c measure tell
average blood sugar for last 3 months
what does fasting blood sugar level tell
current blood sugar level
extent of the wound for each wagner classification
0 = none, superficial, partial thick
1 = partial to full thickness
2-5 = full thickness
explain how pain will be presented in NU
absent/ significantly decreased
explain the temperature of a NU
normal or even increased
what periwound/structural changes will be observed in a NU
dry, cracked skin with callus
fungal infection
peripheral edema
structural deformities of the foot
what ulcer grades indicate padded AFO vs Walking shoe vs total contact cast
total contact = 1,2
walking = 1,2,3,4
AFO = 1,2,3,4
explain the progression of decreased shear forces between total contact, AFO. and walking shoe
total contact = most
AFO = middle
walking shoe = least
explain medical glycemic control between DM1 and DM2
1 = insulin therapy
2 = hypoglycemic agents
medical management of pain/paresthesia includes
anticonvulsants
antidepressants
capsaicin
