Neuropathic Wounds

Question 1

What are the risk factors for neuropathic wounds (such as diabetic food ulcers)?

Answer 1

• diabetes
• impaired healing (hyperglycemia impairs all phases of healing as bacteria proliferates rapidly in high glucose environments)
• vascular disease
• tri-neuropathy (sensory, motor and autonomic)
• mechanical stress
• impaired ROM
• foot deformities
• higher risk of infection
• impaired ability to fight infection
• blunted SxS

Question 2

What is tri-neuropathy?

Answer 2

A combo of sensory, motor and autonomic neuropathy that is usually symmetrical and affects distal nerves first and the severity increases with age, disease duration and glucose control

Question 3

What are the effects of sensory nueropathy?

Answer 3

• poor awareness of trauma to the feet
• occurs gradually
• paresthesias: burning, tingling, and aching (painful and debilitating and gives false sense of sensation)

Question 4

What are the effects of motor neuropathy?

Answer 4

paralysis of foot intrinsics which increase plantar forces and causes foot deformities such as hallux valgus and claw toe

Question 5

What are the effects of autonomic neuropathy?

Answer 5

• altered sweating (dry, less elastic, and cracked skin)
• callus formation (increased pressure)
• alters blood flow due to AV shunting and vasodilation which leaches calcium from the bone

Question 6

When should you suspect a patient has charcot foot?

Answer 6

inflammation, edema, warm, bounding pulse, may have open wound

Question 7

What are the characteristics of neuropathic ulcers?

Answer 7

• round punched out look that may be deep/probe to bone
• peri-wound callus
• often on plntar aspect of foot
• min to mod drainage, eschar is uncommon
• red-pale granulation
• typically pain free (due to poor sensation)

Question 8

How is the Wagner grading scale used for classifiying neuropathic wounds?

Answer 8

0-no open lesions
1- superficial ulcer
2- deep ulcer to tendon, capsule or bone
3-deep ulcer w/ abscess, osteomyelitis, or joint sepsis
4-localized gangrene
5-gangrene on entire foot

Question 9

What are common interventions for diabetic foot ulcers?

What should you not do?

Answer 9

• aggressive debridement except for on the heal
• moist wound environment
• offloading (key)
• monitor closely for infection
• patient education and glucose control (key)
• silver dressings
• growth factors
• skin substitutes

Do not soak feet or use whirlpool

Question 10

What is the gold standard for diabetic foot offloading?

How often should it be changed?

Answer 10

total contact cast

changed every 1-2 weeks

Question 11

How should a shoe properly fit a diabetic patient that doesn’t have an ulcer?

Answer 11

• shape of shoe conforms to foot
• about 1/2 inch space between longest toe and end of shoe
• deep toe box to allow toes to move and spread
• adjustable laces for snug instep fit
• fit snuggly around the heel
• closed toe

Question 12

What glucose level would make you avoid exercise?

How long before a workout should a diabetic eat?

Answer 12

under 70 or over 250 if they have ketosis but over 300 without ketosis

1-2 hours before exercise