Neuropathic wounds

Question 1

Risk factors

Answer 1

DM
Impaired healing
Vascular disease
Tri Neuropathy
Mechanical stress
Impaired ROM
Foot deformities 
Previous ulcer or amputation

Question 2

Impaired healing

Answer 2

All healing phases affected
- Bacteria proliferate rapidly in high glucose environment
- Production/neutrophils
- Impaired chemotaxis, migration and mobility of macrophages
- Impaired function of fibroblasts
- Deficient blocking of normal enzymes that degrade tissue
Endothelial cell dysfunction
impaired cell migration

Question 3

Tri Neuropathy (Diabetic)

Answer 3

Sensory Motor Autonomic
- usually symmetrical
- affects distal nerves first - feet hands
Increased with age, disease duration, glucose control (poor)

Question 4

Sensory

Answer 4

• poor awareness of trauma to feet
  Occurs gradually
  Paresthesias: burning, tingling, aching (painful and debilitating) false sense of protective sensation

Question 5

Motor

Answer 5

• Paralysis of foot intrinsics
• Hallux Valgus
  Claw toe (chart marie tooth foot)

Question 6

Autonomic

Answer 6

altered sweating (dry, less elastic, cracked skin)

• Callus formation (increased pressure)
• Blood flow: AV shunting, Vasodilation

Question 7

Foot Deformities

Answer 7

• Fx and Dislocation = foot deformity and abnormal (suspect if: inflammation ,edema, arm pulse, open wound) pressure/shear forces
• Temp 4-15º - higher with ulcer
  Dx: X ray
  Tx: CASTING 6-12 months

Question 8

Clinical Exam

Answer 8

• Lab Values (fasting glucose, A1c, Albumin, Nails
• Foot deformity- joint subluxation
• Vascular - noninvasive vascular screen (ABI)
• Motor/ROM (STR of ankle/foot mms)
• Flexibility (DF ROM -at least 10º)
• General gait analysis and balance
  Sensory testing - monofilament/Vibration

Question 9

Neuropathic Ulcer Characteristics

Answer 9

• Round/Punched out (tracts, tunnels)
• Periwound callus
• Often on plantar aspect of foot
• min to mod drainage
• Eschar uncommon
• typically “pain free”
• Wound is painful

Question 10

Common Interventions

Answer 10

• Agressive Debridement & callus surcerization
• Offloading - Key
• Patient edu - Key
• Silver Dressings (antimicrobial)
• Growth factors (gel)
• Skin substitutes (MD)

Question 11

Off loading

Answer 11

Reduce pressure, promote slow ambulation ,facilitate “normal” gait as possible
- Total Contact Cast (Gold standard) 1-2 weeks
- Charcot Restraint Orthoic Walker (CREW)
- Boots)
(half shoes) and AFO
- ADs

Question 12

Exercise

Answer 12

• Avoid if glucose >250 with Ketosis or >300 w/o or <70
• Stress = increase insulin requirements
• 17oz hydration before
• 2 hours eat before
• Type 2 no more than 2 days between bouts of ex
• Avoid heavy ex late night and not alone
• Avoid high intensity/impact, head down