Neuropathic Ulcers Flashcards
What are neuropathic ulcers caused by?
Repeated stress on feet that have diminished sensation
Neuropathy is a common factor in almost all of these wounds.
What is the most common cause of neuropathic ulcers? what are some other causes
Diabetes
List some primary neurological conditions that can cause neuropathic ulcers.
- Spina bifida
- HIV/AIDS
- Multiple sclerosis
- Alcoholic neuropathy
- Herniated discs or spinal abnormalities
- Exposure to toxins
- Vitamin B deficiency
- Renal failure
- Trauma
- Surgery
What percentage of patients with diabetes face the risk of foot ulcers?
- 15% - 20%
80-85% of amputations are preceded by a foot ulcer.
What is the mortality rate after amputation in diabetes patients?
50% in 3-5 years
What are the two main types of diabetes? describe each
- Type 1 (IDDM): often presents in childhood, related to pancreatic islet cells and production of insulin
- Type II (NIDDM): body develops a resistance to effects of insulin (most over 40) 90% of them are overweight
What does hyperglycemia do to wound healing?
Slows the wound healing response
- accelerates atherosclerotic process
- impairs function of neurophils, macrophages, and fibroblasts (proliferation)
- decreased function of cytokines, growth factors
- macro/microvascular impairments
- higher risk of infection because of delays in cellular function
- long term = nerve damage to distal nerve fiber
What is glycosylation in the context of diabetes?
- Long-term hyperglycemia leads to glucose binding with proteins to form advanced glycation end products (AGEs)
- This facilitates the formation of irreversible cross-links with collagen = stiffening Connective tissue
Vascular effects of DM
- leading risk factor for CAD, CVD, and PVD
- accelerates rate of atherosclerosis
- causes thickening of basment membrane resulting in decreased delivery of oxygen and nutrients
- less likely to have revascularization if ciruclation problems occur
- patients with DM more likely to have amputation
- smoking can accelerate
What are the key risk factors for neuropathic ulcers?
- Pressure
- Hyperglycemia
- Vascular disease
- Neuropathy
- Mechanical stress
- Abnormal foot function
- Impaired immune response
- Poor vision
- Inadequate education
Peripheral neuropathy: onset and typical progression
-
- gradual onset: painless, or gradual increase in numbness, tingling, burning or pins/needles (dont realize they have neuropathy)
- sudden onset: usually initially painful, then sudden disappearance leaving sensory loss
What are the characteristics of neuropathic ulcers?
- Absent or significantly reduced pain
- position: plantar aspect of foot
- Round, punched-out lesions
- Dry, cracked peri-wound area
- Normal pulses
- Normal or increased temperature
What is the appearance of dry gangrene? cause?
- Dry, black, and shriveled tissue
- no odor
- no discharge
- line of demarcation
- skin above may be health
- caused by lack of nutrition
It is caused by lack of nutrition and has no odor or discharge.
What is the appearance of wet gangrene?
- Painful, purple, swollen tissue
- infected
- malodorous/purulent drainage
- demarcation is ill defined
- caused by excessive moisture
It is caused by excessive moisture and is often infected.
What is the gold standard for assessing sensory integrity in diabetic patients?
Semmes-Weinstein monofilaments
What types of interventions are important for managing diabetic foot ulcers?
- Education
- Non-invasive skin and nail care
- Local wound care
- Orthotics and adaptive equipment
- Off-loading techniques
What are some foot care guidelines for diabetic patients?
- Inspect feet daily
- Always wear socks (inside out if they have seams)
- Do not walk barefoot
- Wash feet daily and dry well
- Maintain good diabetes control
- shoes should fit properly
- do not soak feet
- test water temps
- trim nails straight across
- regular goot exams
- physician removes corns and calluses report wounds or foot changes immediately
- maintain good disabetes control
What is Total Contact Casting (TCC) used for? and how does it assist with healing
- To improve weight bearing over the entire lower leg
- allows WB forces to be distributed over larger area
- rigid cast helps with edema and improve local circulation
- immobilized foot and reduces shearing forces
- protects foot from trauma and microogranisms
- increases patient adherene to care because it allows activity
It helps distribute weight-bearing forces over a larger area.
What are the contraindications for Total Contact Casting?
- Active infection: Presence of gangrene, Osteomyelitis
- Fluctuating edema
- Inability to care for cast
- ABI < 0.45
What should physical therapists educate patients about regarding diabetes management?
Awareness of blood sugars and the impact of physical activity
What type of exercise is recommended for diabetic patients to lower hyperglycemia?
Minimum of 150 minutes of moderate-intensity aerobic activity per week
Examples include walking, cycling, and swimming.
Polyneuropathy: sensory
- unable to sense pain and pressure
- 50% of patients unaware of protective sensation loss
- unable to perceive 5.07 monofilament = risk of ulceration/loss of protective sensation
poly neuropathy: motor neuropathy:
what is lost/what can this predispose them to
- loss of intrinsic muscularture, resulting in clawed toes and eventually foot drop
- may lose ankle reflex
- atrophy predisposes to plantar pressure and shear forces
- cause foot to be less stable in gait
polyneuropathy: autonomic
- disturbances in sweat and oil production (callus formation), blood flow
- leads to dry, less elastic, cracked skin
- increased risk of osteopenia and foot fracture
neuropathic ulcers
exam findings
Neuromuscular; vascular; MSK; Integ
- Neuromusclar: clawed toes, rigid, insensate foot
- vascular: signs of PVD
- MSK: skeletal changes, charcot joint, gait dysfunction, toe deformities
- integ: hypertrophic nails, hyperkeratotic lesions, dry skin with fissues (autonomic response), callous, rash, infections, signs of trauma, gangrene
charcot foot
- relatively painless, degenerative arthroplasty caused by underlying neuropathy
- skeletal damage due to neuropathy
- progressive OA: joint dislocation, pathologic fx, deformities
- concavity of arch lost
- toes lose contact with surface
- shear forces on MT heads
- demineralization of bones/osteopenia
- motor denervation cause muscle imbalance
classification of neuropathic ulcers
- 0: foot at risk; thick calluses, bone deformities, clawed toes, and prominent metatarsian head
- 1: superficial ulcers: total destruction of thickness of the skin
- 2: deep ulcers: penetrates through skin, fat, ligaments, and not affected bone (infected)
- 3: abscessed deep ulcers: limited necrosis in toes or the foot
- 4: limited gangrene: limited necrosis in toes or the foot
- 5: extensive gangrene: necrosis of the complete foot with systemic effects
diabetes management program
- diabetes self management education/training
- medical nutritional therapy
- physical activity
- pharmacologic management
- glucose monitoring - blood glucose/HbA1c
- challenges: education, depression, and burnout adherence
PT tests and measures for neuropathic ulcers
- inspection
- assessment of circulation
- assessment of sensory integrity: monifiliments (4.17 = normal)
- virbation, sharp/dull
- ankle reflexes
Wound care/medical Interventions for neuropathies/neuropathic ulcers
- education
- non-invasive skin/nail care
- local wound care
- orthotics and adpative equipment
- total contact casting
- cast shoes, dynamic splints, neuropathic walker
- off-loading
- medical surgical management
What are some non-invasive skin/nail care (local wound care)
- take care of nails and cuticles
- manage calluses and heel fissures
- daily application of moisturizer to minimize dry, cracked skin(not between toes)
- wound care: consistent with appearance (clease/debride necrotic tissue)
What are some adjunct modalities for (local wound care)
- ultrasound
- negative pressure wound therapy
- electrical stimulation
- growth factors
Orthotics/shoes, socks and blocks
- shoes: soft leather that conforms to abnormalities and allows for depth to accommodate inserts (large toe box)
- shank rocker bottom to facilitate motion and decrease pressure of forefoot/great toe
- sock: no seams, cotton/acrylic blend, cushioned with non-restrictive top
- blocks: shoe fillers for an area of ampulation
- orthotics: to provide accommodation for foot contours; soft but semi-rigid
medical management for neuropathic ulcers
- tight glycemic control
- management of paresthesia’s/neuropathic pain/infection
surgical interventiosn for neuropathic ulcers
- debridement
- antimicrobial bead implantation
- stabilization of MSK deformities/charcot deformity
- amputations for gangrenous
PT interventions for neuropathies/neuropathic foot ulcers
- education: awareness of blood sugar/impact of physical activity
- gait and mobility training
- NWB/PWB if needed to offload pressurre
- ROM exercises
- aerobic exercise: lower hyperglycemia, weight loss
