Neuropathic Wounds Flashcards
What are the classifications of diabetes?
Type 1
Type 2
Gestational (during pregnancy)
Secondary (genetic defects, infections, diseases of exocrine pancreas, drug-induced, etc.)
Which classification of diabetes is most common?
Type 2 (85-90%)
secondary to history, lack of exercise, obesity, ethnic background, age, history of gestational diabetes, etc
Neuropathic is termed a “Tri-neuropathy,” what does this mean?
Sensory
Motor
Autonomic
What does the SENSORY portion of the tri-neuropathy consist of?
Diminished sensation
leading to
Lack of protective sensation
(Caused by damage to small nerve cells)
What does the MOTOR portion of the tr-neuropathy consist of?
Muscle weakness
leading to
Changes in foot shape
leading to
High peak pressures during WB activities
(Caused by damage to large nerve fibers)
What does the AUTONOMIC portion of the tri-neuropathy consist of?
Decreases sweat and oil production
leads to
Dry inelastic skin
(Caused by damage to large nerve fibers and sympathetic ganglion)
What is the impact of neuropathy on gait?
Shorter stride length
Longer duration of time in the stance phase
Slower gait speed
Wider BOS during gait
Greater step variability
Elevated plantar pressures
Reduced ankle ROM (DF (need 10 deg) and 1st MTP extension)
What are MSK changes you might see with neuropathic wounds?
Ankle Equinus
Bunion
Pes Cavus
Hammer toes/Claw toes
Charcot foot
What is ankle equinus?
< 90 degrees of ankle DF
What is the significance of having pes cavus?
Abnormal pressure points placed on the foot
Poor dispersion of force–possible wound formation
What is a charcot foot?
Flat foot with a “rocker” bottom
Joint subluxation causes midfoot arch to fall
http://www.bonetalks.com/footcharcot/
What is the road to neuropathic wounds?
Neuropathy
- Sensory
- Motor
- Autonomic
leading to
Foot deformity
- Loss of fat pad
- Callus formation
leading to
Diabetic foot ulcer
- Due to mechanical trauma
What are the characteristics of Neuropathic ulcers?
LOCATION:
Weight-bearing surface of foot or dorsal digits of toes
TISSUE:
Callus or blister, slough, may probe to bone, neurotic with PAD
Red but not granulated
Periwound callus
PAIN:
NONE! Until infected, then deep throb
SKIN:
Dry, thick, scaly, hyperkeratonic
EXUDATE:
Varies, depending on infection (serosanguinous?)
What are the stages of neuropathic ulcer development?
Callus formation
Subcutaneous hemorrhage
Breakdown of skin
Deep foot infection with osteomyelitis
What are the causes of diabetic wounds?
Friction
Shear
Pressure
Poorly fitted shoes
(ALL ARE ENHANCED IN PRESENCE OF SEEMINGLY BENIGN FOOT DEFORMITIES)
Charcot deformity
Traumatic injury
Forces on the foot
Vertical
Anteroposterior shear
Mediolateral shear
What are common causes of trauma?
Walking barefoot (NEVER)
Burns
What is the PT tx for neuropathic wounds?
PATIENT EDUCATION
- Blood glucose
- Properly fitting shoes
- Nail and callus care
- Skin care
- Diabetic or molded shoes if foot deformities are severe
IMPROVING ROM AND GAIT MECHANICS
OFF-LOADING
STANDARD WOUND CARE TECHNIQUES
What is Normoglycemia?
Fasting < 100 mg/dL
What is impaired fasting glucose?
100-125 mg/dL
What is causation for dx of diabetes?
> 125 mg/dL
When does wound healing cease to continue with diabetes?
> 200 mg/dL
What is the HbA1C score and what is the goal number for a diabetic?
Measures average plasma glucose concentration
GOLD STANDARD FOR GLUCOSE CONTROL
Want 6.5 for diabetics
What is the rationale for using footwear for off-loading?
To remove pressure completely from the site of a plantar wound or to distribute pressure over a greater surface area
What is the gold standard for a patient with a diabetic foot ulcer, and what is it used for?
Total contact cast (TCC)
Optimized pressure redistribution along entire leg and plantar surface of the foot
Increases adherence
Contraindications
- PAD, ABI < 0.7
- Infection
Usually changed after 1-2 days at first
Then weekly until shoe can be worn
What are some alternatives to TCCs?
Wound healing shoe
Accomodative dressing
Post-op shoe with plastazote inserts
CAM walker boot
PWB or NWB with AD
WC ambulation only
What are Plastazote inserts?
Soft, conforming material used to make shoe inserts
Allows for greater distribution of pressure across plantar surface
What is the management for a post-healing foot?
Medicare therapeutic foot bill
- Patients with DM can get a pair of shoes each year from medicare if they have a documented impairment
- Pays for diabetic shoes and inserts
- Patient must have DM, previous amputation, ulceration, pre-ulcerative calluses, foot deformities, or poor circulation
- Must be under care of physician who is managing DM
