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211 exam 2
Diabetic Ulcers and the Diabetic Foot
| Question | Answer |
|---|---|
| sensory neuropathy | affects the ability of the patient to feel pressure/injury |
| motor neuropathy | affects the motor nerves-weakens intrinsic muscles of the foot causing foot deformities |
| autonomic neuropathy | affects secretion glands and causes excessively dry skin that is more likely to split. |
| symptoms of peripheral neuropathy | Sharp, jabbing, throbbing or burning pain Sensitivity to touch Lack of coordination/falling Muscle weakness Increased heart rate or drops in blood pressure Decreased bladder function and digestive problems |
| how does peripheral neuropathy affect the skin? | Dryness-due to lack of moisture from secretion glands Increase perspiration or not being able to perspire |
| onset of peripheral neuropathy | Gradual onset of numbness/tingling in feet and hands, which can spread upward to legs and arms |
| purpose of Semmes- Weinstein monofilament test | Used to measure different degrees of sensation |
| Each monofilament has a different ____ that will make it bend. If you apply enough force to make the monofilament bend- then the prospective amount of force was applied | gram-force |
| Many agencies just do a simple ___ g monofilament to determine if the patient has loss of sensation or not | 10 |
| what causes autonomic neuropathy | Damage to nerves that control automatic body functions |
| what can autonomic neuropathy affect? | BP, temperature control, digestion, bladder and sexual function |
| how does autonomic neuropathy affect the skin? | Affects secretion glands and causes excessively dry skin that is more likely to split (feet not being able to sweat and provide needed moisture to the skin). |
| motor neuropathy causes damage to | nerves that innervate peripheral muscles |
| what does motor neuropathy cause | Causes foot deformities that increases risk of ulcer development Causes weakness that affect the weight bearing on the foot- which increases the risk of ulcer development Can lead to broken bones and joint dislocations |
| perfect storm for wounds | Lack of sensation Excessively dry and cracked skin Weakness and related foot deformities |
| diabetic ulcer characteristics | located on the foot proceeded by a callous or blister Punched out appearance, surrounded by callous or epibole caused by weight bearing (pressure) painless- causing delay in patient seeking care no typical signs and symptoms of infection |
| wagers classification of diabetic foot ulcers | 5 grade scale from intact skin to extensive gangrene |
| Wagner grade 0 | skin intact but boney deformities (foot deformities) lead to “foot at risk |
| Wagner grade 1 | superficial ulcer |
| Wagner grade 2 | deeper full thickness ulcer without bone involvement or abscess formation |
| Wagner grade 3 | Deep ulcer with cellulitis or abscess formation- often with osteomyelitis |
| Wagner grade 4 | partial gangrene of forefoot |
| Wagner grade 5 | extensive gangrene |
| treatment for diabetic ulcers | Offload the wound Debride the associated callous Monitor for signs of infection- Address associated foot deformity~ Ambulatory patients will need bracing or custom orthotics to offload Choose appropriate dressing |
| other considerations for tx of diabetic ulcers | Blood sugar management-imperative for wound healing Smoking cessation Dietary education Medication management Edema management- to improve circulation |
| why do blood sugars affect healing of diabetic ulcers | High blood sugars can cause calicifed arteries- impedes blood flow, affects the cellular response to tissue injury – delayed function of immune cells= increased risk for infection |
| common diabetic foot deformities | Hammertoe foot deformity Hallux Valgus deformity Pes Plano Valgus deformity Pes Planus deformity Charcot Foot |
| hammertoe deformity | Most common deformity of the lesser toes |
| what causes hammertoe | chronic, sustained imbalance between flexion and extension forces applied to the lesser toes |
| how does the IP, MTP and DIP joints look in hammertoe | progressive proximal interphalangeal joint flexion deformity- the MTP and DIP joints compensate by hyper extending. |
| what is hammertoe associated with | loss of fat pad in the ball of the foot |
| where will wounds develop in hammertoe? | on the dorsal PIP joints or the planter MTP joints |
| hallux valgus deformity | The first MTP joint of the foot is gradually subluxed Causes lateral deviation of the great toe which causes medial protrusion of the first met head |
| what develops as a results of hallux valgus | first met head develops a boney protrusion and extra soft tissue- bunion Wounds will appear on the bunion, the great toe or the second toe. |
| pes plano valgus deformity | talus subluxes medially and the calcaneus is in valgus. This shortens the heel cord |
| how does pes plano valgus deformity look? | rolled-in appearance of the ankle and the heel appears to be rolled out. |
| how does the arch look with pes plano valgus | collapses in standing- typically this is a non-fixed deformity. The foot will appear normal in sitting but collapse in weight bearing (correctable with orthotics/braces) |
| pes planus | Defined by the loss of the medial longitudinal arch of the foot Nearly all of the arch contacts the ground |
| what does pes planus cause | continued progressive deformity of the foot and ankle |
| charcot foot deformity | Also known as “rocker bottom” deformity. This is the most serious diabetic foot deformity Acute Event: bones become weak and break. The joints of the foot dislocated |
| how does charco foot progress | progresses as the patient continues to bear weight on the foot. Easy for the patient to do as they cannot feel pain |
| early signs of charco foot | foot is red/hot/swollen without pain or known injury- |
| WB protocol for charco foot | NWB x 6 months |
| why is charco foot often missed? | missed due to lack of pain sensation. The patient will continue to walk on the foot- causing further joint dislocations and fractures. |
| tx for charco foot | Immediate immobilization/non weight bearing- recommended 6 months NWB Use of a cast of a removeable cast boot Progression to custom shoes/bracing |
| surgery for charco foot | Realignment procedures such as osteotomies and fusions Ostectomies: removal of the boney prominence that will cause the skin breakdown/wound/infection |
| offloading diabetic ulcers and charco foot | Assistive Devices Total Contact Cast Post surgical removable boot Custom AFO Custom Orthotic Diabetic shoes Rocker Bottom Shoes |
| assistive device options for charco foot | Wheelchair Crutches Walker Knee scooter |
| total contact cast | Used to redistribute pressure over the entire planter surface of the foot and away from the wound Typically applied by a podiatrist or in wound clinics used for charco foot in early phases |
| how is total contact cast applied? | way to intimately contact the entire contour of the foot |
| how much does total contact cast cost? | $250 |
| what does total contact cast require? | adequate circulation and a non- infected ulcer that is not heavily draining The ulcer cannot be deeper than it is wide |
| offloading walker boots | redistribute pressure over the entire plantar surface of the foot~not custom fit, so the foot may have more issues with shearing compared to a TCC |
| when is offloading walker boot used for charco foot | protect the Charcot foot during the acute phases of swelling, fractures and dislocations (ideal for this if there is a wound on the foot) |
| advantages of offloading walker boot | Advantage is that it is removable and you can observe the Ulcer more |
| cost of offloading walker boot | $200-250 |
| goal of custom orthotic/AFO | reposition the foot so that it sits in subtalar neutral in weight bearing |
| who is custom orthotic/AFO ideal for? | non fixed foot deformities such as pes plano valgus |
| how does custom orthotic/AFO help wounds? | Redistributes pressure away from the wound/callus Custom fit reduces sheering |
| what does decision to do custom orthotic vs brace depend on? | the location of the wound and flexibility of the foot deformity |
| how much do rocker bottom shoes reduce pressure | by 30%. Paired with an orthotic, pressure is reduced by 50% |
| purpose of rocker bottom shoes | Rigid sole reduces movement of the foot joints, specifically extension of the MTP joint This prevents movement of the tissues of the plantar aspect of the foot and distributes the forefoot load over larger areas |
| how does rocker bottom shoe affect walking? | Makes walking easier by pushing the weight from the heel to the forefoot during stance phase of gait |
| comprehensive diabetic foot exam | dermatological considerations nerve considerations osseous considerations vascular considerations shoe gear considerations |
| dermatological considerations for diabetic foot exam | dry skin, fungal infection, callus, interdigital lesions, ingrown nail, ulcerations |
| nerve considerations for diabetic foot exam | nerve pain or lack of sensation |
| diabetic footcare recommendations | Yearly comprehensive foot examination Yearly diabetic footwear with inserts changed every 4 months 2-3 months routine foot care done by a professional Daily foot evaluations by family/caregivers |
| how often should diabetic shoe inserts be changed? | every 4 months |
Created by:
bdavis53102
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