Unit 1 - Week 3 - Wound Etiology; Neuropathic/Diabetic Ulcers

What is the leading cause for amputations?

diabetes

1/5 people with diabetes

don't know they have it

Lifetime risk of neuropathic ulcers with diabetes

25%

Diabetes

Disorder of carb, protein, and fat metabolism due to the body's inability to produce insulin or use insulin appropriately.

Juvenille diabetes

Type 1 A

IDDM

insulin dependent diabetes mellitus

NIDDM

non-insulin-dependent diabetes mellitus (type 2 diabetes)

Type 1A diabetes

Immune mediated destruction of the beta-islet cells of the pancreas. Inability to produce insulin. GENETIC predisposition IDDM

Type 1B diabetes

idiopathic diabetes IDDM

Type 2 Diabates

insulin resistance, Impaired secretion, less potent insulin production NIDDM

Hemoglobin A1c

test that measures blood sugar over the course of 3 months.

Normal A1c

less than 5.7%

Pre-diabetic A1c

5.7-6.4%

Diabetic A1c

6.5% or higher

T or F: 50% of diabetics will have a contralateral ulcer within 18 months of amputation

TRUE

T or F: 50% of diabetics will have a 2nd amputation in 3-5 years after their 1st.

TRUE

Post amputation mortality rate for people with diabetes after 5 years for a toe

41%

Post amputation mortality rate for people with diabetes after 5 years for below the knee

63

Post amputation mortality rate for people with diabetes after 5 years for above the knee

86

Which amputation has the highest mortality rate among diabetics? Toe, Below the knee, or Above the knee?

Above the knee. 86% mortality in 5 years.

Theories for diabetes related tissue damage

-Hyperglycemia

-Glycosylated proteins cause tissue damage

-Accumulation of sorbitol, due to the breakdown of glucose, resulting in tissue destruction.

How might hyperglycemia cause tissue damage?

-Changes RBC, platelets, and capillaries.

-Alters blood flow

-Increases microvascular pressure.

List the risk factors for neuropathic ulcers and delayed healing.

-Vascular disease

-Neuropathy

-Mechanical stress/abnormal function

-Inadequate footwear

-Impaired healing/immune response

-Poor vision

Delayed healing in Diabetes

-Ulcer characteristics

-disease characteristics

-Inadequate care and education

Diabetes can affect

Kidneys and eyes

Diabetes is the leading cause of

Retinopathy, glaucoma, and cataracts

Why is vascular disease a risk factor for neuropathic disorders?

Diabetics have an accelerated rate of atherosclerosis, leading to vascular disease

Neuropathy and Amputation

Causes 82% of amputations

Why does sensory neuropathy lead to ulceration?

50% of those with sensory neuropathy are unaware that they have lost protective sensation.

Autonomic neuropathy leads to

Decreased sweating, bone vasodilations, orthostatic hypotension

Diabetic neuropathic osteoarthropathy

Inflammation phase characterized by foot edema, erythema, and increased temperature leading to bone and articular destruction, progressing to multi-joint dislocations and possible fractures.

Two theories for diabetic neuropathic osteoarthropathy

-Neurovascular theory

-Neurotraumatic theory

What is the neurovascular theory?

Hyperemia (excessive blood flow) causes increased pressure and deep tissue ischemia within the foot, leading to inflammation and breaking of the bone.

What is the neurotraumatic theory?

Trauma in the presence of sensory neuropathy goes undetected.

Foot changes associated with neuropathic ulcers

-Impaired ROM

-Foot deformities

-Prior amputations

What motion limitations are associated with neuropathic ulcers?

Great toe extension, dorsiflexion, subtalar joint movement.

Increased vertical pressure and horizontal shear.

what foot deformities are associated with neuropathic ulcers?

Pes aquinas, hallux limitus/rigidus, hallux valgus, varus in toes, charcot's foot, tailor bunion.

Charcot's foot

TMT joint @ Mid-foot collapses, leading to a pressure point on the bottom of the foot.

Pain with neuropathic ulcers

Typically none due to paresthesia

Location of neuropathic ulcers

Plantar aspect of the foot, midfoot with charcot deformity, forefoot under calluses, heel, friction areas, dorsal and/or tips of toes if clawed, medial 1st, lateral 5th met MTP joints

Presentation of neuropathic ulcers

-Rounded/punched out

-Callused rims

-Minimal drainage

-Eschar is uncommon

Periwound/structural changes of neuropathic ulcers

dry, cracked skin, callus, foot structural deformities.

Pulses with neuropathic ulcers

Normal, or accentuated due to hardened arteries.

Temperature of neuropathic ulcers

normal or increased

PT classification test for neuropathy and neuropathic ulcers

Wagner scale

PT circulation tests for neuropathy and neuropathic ulcers

pulses, capillary refill, doppler ultrasound, ABI, TBI

PT sensory integrity test for neuropathy and neuropathic ulcers

Monofilament testing

Wagner scale grade 0

No open lesion, may have deformity or cellulitis.

Wagner grade 0 extend of wound

None, superficial or partial thickness

Wagner scale grade 1

superficial ulcer

Wagner grade 1 extent of wound

Partial or full thickness

Wagner scale grade 2

Full thickness. Deep ulcer to tendon, capsule, or bone.

Wagner scale grade 3

Full thickness! Deep ulcer with abscess, or osteomyelitis (infection of the bone) or joint sepsis.

Wagner scale grade 4

Full thickness. Localized gangrene

Wagner scale grade 5

Full thickness. Gangrene of entire foot.

What exam is done for all extremity open wounds?

Pulse exam

Perform ABI for all patients with what?

Plantar ulcerations, decreased/absent pulses, signs and symptoms of arterial insufficiency, history of peripheral vascular disease or coronary artery disease

Perform capillary refill for patients with what?

Digital ulcers, abnormal ABI

Perform sensory integrity for patients with what?

Neuropathic ulcerations, diabetes, plantar foot ulcers, neurological injuries

Refer to physician when ABI is_____

<0.8

vessel wall calcification can _____ ABI

inflate

Semmes-Weinstein Monofilament Testing procedure

-Occlude vision

-Begin with 5.07 filament to assess protective sensation, bend the monofilament against the skin then release.

-Avoid calluses

-test each location randomly 3X

Supplement with 128-Hz tuning fork on

first metatarsal head or malleolus to asses vibration perception

What does it indicate if the patient can't feel the 4.17 monofilament?

Decreased sensation

What does it indicate if the patient can't feel the 5.07 monofilament?

Loss of protective sensation

What does it indicate if the patient can't feel the 6.10 monofilament?

Absent sensation

Reasses if 20-50% decrease in wound area is not seen within

1st month of treatment

Good prognosis for neuropathic ulcers

-Wagner 1 or 2

-present for <2 months

-better glycemic control

-high ABI

Poor prognosis for neuropathic ulcers

-large size

-wagner >3

-infection

-smoking

What increases amputation by 154%?

Infection

average time for neuropathic ulcer healing

12-14 weeks.

Healing with conservative management of local wound care, unloading and treatment of infection

90%

do forefoot, or heel ulcers heal faster?

Forefoot ulcers.

At what blood glucose concentration is exercise contraindicated?

<70mg/dL

Exercise recommendations for blood glucose 70-100 mg/dL

provide snack and monitor, may require MD referral.

Exercise recommendations for blood glucose 100-250 mg/dL

proceed with the exercise program

Exercise recommendation for blood glucose >250 mg/dL

Check ketones, if ketones are >1.5 mmol/L, no exercise.

reduction in blood sugar can occur how long post-exercise?

6-15 hours, and can persist for up to 48 hours

If wearing socks with seams

turn them inside out so the seams don't cause undue pressure

Wound care recommendations

-Off-loading

-Pare the callus so it is flush with the epithelial surface.

-Use petroleum based moisturizer.

-Use toe spacers if dressing the foot

total contact cast

short leg cast used to treat uninfected grade 1 or 2 neuropathic ulcers

how does a total contact case assist wound healing

-molded to the foot and leg, and disperses weight bearing over a large area.

-immobilizes the foot and protects it from trauma and microorganisms.

-rigidity controls edema

contraindications for total contact casts

osteomyelitis, gangrene, fluctuating edema, infection, ABI <0.45

negatives of a total contact cast

it is thick, and could pose a risk for falls if the person isn't stable.

How to alter gait pattern for those with neuropathic ulcers?

Step-to-Step pattern decreases pressure on the great toe or forefoot by 53%. Slower gait also decreases pressure.

common balance assessments for neuropathy/neuropathic ulcers

Berg, tug, functional gait

PT interventions for neuropathic ulcers/neuropathy

-ROM

-Strengthening

-Aerobics

Strengthening what muscles is important for neuropathy/neuropathic ulcers?

Hip external rotators and ankle inverters to decrease pronation

Padded AFO ulcers

1-4

Walking shoe ulcers

1-4

What decreases shear forces the most

Total contact cast

2 multiple choice options

permanent footwear recommendations

-For those with severe deformities or amputations.

-Minimize plantar pressures and shear.

-should be 1/2 inch longer than the longest toe, with a snug heel.

-Extra depth toe box.

-<1 inch heel height.

-laces for snugness.

Refer out when:

-ABI <0.8

-Failure to respond

-Suspected infection

-Exposed bone/capsule