Wound etiology - neuropathic ulcers Flashcards
Diagnoses at risk of neuropathic ulcers
- Diabetes
- Hansen’s disease
- Spina bifida
- Incomplete SCI
- Charcot-Marie Tooth
Causes of neuropathic ulcers
- Sensory neuropathy
- motor neuropathy
- mechanical stress
- high foot pressure
- ill-fitting footwear
- trauma
Indicators of high stress on the skin
- redness
- swelling
- maceration
- heat
- dry skin
- nonblanchable skin
- ulceration
How much pressure is required for protective sensation?
10 grams of pressure
5.07 monofilament
How much pressure indicates absent sensation?
75 grams
6.1 monofilament
How does strength contribute to neuropathic ulcers?
Abnormal strength leads to deformity, stress, and ulceration
What can lead to plantar ulceration?
Decreased ankle dorsiflexion
What is Charcot fracture?
- Neuropathic fracture caused by fracture and collapse of tarsal bones
- Leads to mid-foot ulcerations
- Presents with rocker bottom
What are the two scales for staging/classifying neuropathic ulcers?
- Wagner scale
- University of Texas classification system
What are the stages on the Wagner scale?
0 = preulcer; healed ulcer; presence of bony deformity
1 = Superficial ulcer w/o subcutaneous tissue involvement
2 = Ulceration through the subcutaneous tissue; may expose bone, ligament, tendon, or jt. Capsule
3 = deep ulcer with infection
4 = Gangrene of digit
5 = Gangrene of the foot requiring disarticulation
What are ways to prevent neuropathic ulcers?
- Screening – history, monofilament testing
- Patient education – neuropathy, rick factors for ulceration, etc.
- Self – inspection
- ROM exercises
- Proper footwear (orthotic referral)
- Education / disease control
What are guidelines for footwear fitting?
- Shape of the shoe conforms to foot
- ½ - ¾ inch b/w end of shoe & longest toe
- First mp jt. @ widest part of shoe
- Toe box allows toe spread & toe clearance
- Lace for snug fit @ instep
- Snug fit around heel
What is the standard of care for neuropathic ulcers?
Off-loading through total contact casting (TCC)
What are other interventions for neuropathic ulcers?
- Clean, debride and dress the wound
- Total contact casting – gold standard
- Walking splint (AFO)
- Healing footwear – molded plastazote or wedged shoes
- Assistive devices for gait in PWB or shorter steps to decrease forefoot pressure
What is total contact casting?
Application of a cast in contact with the skin throughout the lower leg, so that WB occurs throughout the lower leg, and not just on the foot
