Wound Management (PT) Flashcards
neuropathic ulcers
- aka diabetic ulcerations
- incidence: 15-25%
diabetes impact on amputations
-DM is responsible for over 600k amputations annually
etiology of diabetes-related tissue damage
- hyperglycemia: changes RBCs, palelets, and capillaries; alters blood flow; increases microvascular pressure
- glycosylated proteins cause tissue trauma
- accumulation of sorbitol, d/t breakdown of glucose, results in tissue destruction
risk factors that contribute to NUs and delayed healing
- vascular dz
- neuropathy
- mechanical stress
- abnormal foot fxn and inadequate footwear
- impaired healing and immune response
- poor vision
- ulcer characteristics
- dz characteristics
- inadequate care and education
vascular disease
- increased risk for peripheral vascular dz w/ DM
- accelerated atherosclerosis
- thickening of basement membrane
what is the major contributing factor to neuropathic ulcers?
neuropathy
neuropathy
- MC complication of DM
- symmetrical and distal
- affects sensory, motor, and autonomic systems
- causes: neural ischemia, segmental demyelination
sensory neuropathy
- 50% of pts unaware they have lost protective sensation
- lack of protective sensation = lack of early detection to irritation or trauma
- paresthesias
at what point in sensory neuropathy is a person at risk for ulceration?
if unable to perceive 10g of pressure
motor neuropathy
- intrinsic muscle weakness/atrophy
- decreases foot stability
- leads to deformities
- increased pressure and shear forces to foot
autonomic neuropathy
- dry, cracked skin d/t decreased ability to sweat
- increased rate of callus formation
- arteriovenous shunting leads to decreased perfusion
- uncontrolled vasodilation lead to osteopenia
mechanical stress
- abnormal or excessive forces predispose to ulceration
- high plantar pressures overload tissue’s ability to repair itself
impact of abnormal foot function and inadequate footwear
- impaired ROM
- foot deformities
- prior ulcer/amputation
- poor footwear
impact of impaired healing and immune response
- decreased ability to build new tissue and fight infection
- increased frequency of osteomyelitis, soft tissue infections, candida
- impairs all 3 phases of would healing
poor vision
- DM is leading cause of retinopathy, glaucoma, cataracts
- increases risk of trauma
- decreases ability to perform adequate foot care
characteristics of ulcers
- larger and deeper wounds take longer to heal
- woulds present for longer time and take longer to heal
increased risk for diseases
-poor glycemic control is associated w/ increased risk of long-term complications
common types of inadequate care and education
- lack of cutting edge knowledge
- delayed referrals
- poor adherence to clinical guidelines
- minor short-term complications but major long-term complications
- pts don’t understand the link b/w euglycemia and long-term complications
- absence of pain or short-term effects decreases pt adherence
3 main PT tests and measures for NUs
- circulation
- sensory integrity
- gait analysis
tests of circulation
- pulses
- doppler US
- ABI
indications for circulation issue
- all open wounds
- decreased or absent pulses
- s/s of arterial insufficiency: depends on location
- hx of PVD
when to refer for circulation issue
- arteriography or transcutaneous oxygen measurements if fail to respond
- refer to vascular specialist if very low ABI
main test for sensory integrity
semmes-weinstein monofilament
semmes-weinstein monofilament
- occlude pts vision
- begin w/ 5.07 monofilament
- avoid calloused areas
- each location tested randomly 3x
indications for sensory integrity testing
- all neuropathic ulcers
- all pts w/ DM
- all pts w/ plantar foot ulcers
monofilament size vs. pressure produced
- 4.17: 1 gm pressure: decreased sensation
- 5.07: 10 gm pressure: loss of protective sensation
- 6.10: 75 gm pressure: absent sensation
classification system used for NUs
Wagner Classification System
Wagner Classification System grades
- 0: no open lesions, may have deformity or cellulitis
- 1: superficial ulcer
- 2: deep ulcer to tendon, capsule, bone
- 3: deep ulcer w/ abscess, osteomyelitis, or joint sepsis
- 4: localized gangrene
- 5: gangrene of entire foot
what is the 5PT method
- pain
- position
- presentation
- periwound
- pulses
- temp
pain
- lack of pain complaint d/t neuropathy
- possible paresthesias
position
- plantar foot
- plantar aspect of metatarsal heads
- plantar aspect of midfoot if Charcot deformity
- may occur under calluses
- may occur in areas of pressure/friction from inappropriate footwear
presentation
- round, punched-out lesions
- callused rim
- minimal drainage unless infected
- eschar or necrotic material uncommon unless infected
periwound (and structural changes)
- skin is dry, cracked
- callus present
- structural deformities: claw toes, rocker-bottom foot, prior amputation
pulses
- normal
- decreased
- or may be accentuated w/ vessel calcification
temp
- normal
- may be increased in areas of reactive hyperemia or infection
good healing prognosis for NUs
- smaller, superficial (Wagner grade 1 or 2)
- present for < 2 months
- ulcers decreasing in size w/i 4 weeks of tx
poor healing prognosis for NUs
- large size
- risk of amputation 154x greater w/ infected ulcers
- if 20-50% decrease in size not noted in first month of tx
who all makes up the team approach in a DM patient?
- primary care provider
- surgeon
- podiatrist
- nutritionist/diabetic educator
- endocrinologist
- orthotist
- psychological counselor
- social worker
patient/client related instructions
- dz process/management of DM
- role of exercise and safety guidelines: benefits, risks, contraindications
- general guidelines about what to do
- risk factor reduction
- daily foot checks
- poper footwear
- toenail care
- demonstrate what decreased protective sensation “feels” like
infection precautions
- may not show signs of infection d/t decreased inflammatory response/PVD
- request culture and sensitivity for wounds that fail to respond to appropriate interventions
- osteomyelitis must be treated surgically
BS monitoring precautions
- hyperglycemia common w/ infections and uncontrolled DM
- hypoglycemia may occur
keys to local wound care
- offload the neuropathic ulcer
- pare (trim) callus flush w/ epithelial surface
- use petrolatum-based moisturizer daily
- use toe spacers if enclosing toes in bandage
possible adjuncts for local wound care
- negative pressure wound therapy
- US
- electrical stimulation
- growth factors
total contact casting
- modified short leg casts used for Wagner grade 1 or 2 ulcers
- assists wound healing
- cast is molded to foot and leg, dispersing weight-bearing forces over large area
- cast rigidity controls edema
- immobilization of foot protects from trauma and microorganisms
- assist w/ pt adherence
contraindications to total contact casting
- osteomyelitis
- gangrene
- fluctuating edema
- active infection
- ABI less than .45
gait and mobility training
- partial weightbearing gait w/ assistive device
- alter gait pattern to decrease plantar pressure
- footwear modifications
therapeutic exercise
- ROM exercises: assess/address great toe extension, talocrural dorsiflexion, and subtalar joint motion
- aerobic exercise: assists w/ glycemic control and weight loss
temporary footwear options
- felt or foam inserts
- padded ankle-foot orthoses
- walking shoes
benefits of temporary footwear
- provides safe ambulation, pressure reduction, room for bandages
- can use when total contact cast is not an option
permanent footwear
- shoes should be about 1/2 inch longer than the longest toe w/ snug heel fit
- shoe last should match foot shape
- extra-depth toe box
- heel height < 1 inch
- soft, moldable materials
- soft inserts may decrease pressure
- fit shoes at middle of day
- break in shoes gradually
- pts w/ severe foot deformities or amputations should be referred to orthotist
medical interventions
- glycemic control: even 1% decrease in A1c associated w/ improvements in many complications
- manage neuropathic pain/paresthesias: anticonvulsants, antidepressants, capsaicin
- management of concomitant arterial insufficiency
- antibiotic therapy: MC infections of staph or group A strep
- radiological assessment
surgical interventions
- debridement: necrotic tissue, osteomyelitis
- incision and drainage
- antimicrobial bead implantation
- surgery to address abnormal foot function of limited tissue perfusion
- revascularization surgery
- amputation: gangrene or wagner grade 4 or 5 ulcers
