Lecture 10 (Neuropathic)

What is the etiology of neuropathic ulcer?

• Peripheral Neuropathy + Repetitive Trauma

What do mortality rates of DM look like?

• What is the age prevalence of it?

• 7th Leading Cause Of Death

  • < 44 yrs → 4%

  • 44-64 yrs → 18%

  • > 65 yrs → 29%

What is the difference between Type 1 & 2 DM?

• What are each also known as?

• What is medical tx for each?

• Type 1 → Autoimmune, Insulin Deficiency

  • aka Juvenile Diabetes

  • mTx: Insulin, Then Lifestyle

• Type 2 → Acquired, Insulin Resistance

  • aka Adult-Onset Diabetes

  • mTx: Lifestyle, Then Metformin, Then Insulin

What does polyneuropathy mean?

• What is impaired for each part?

• Involvement Of Different Nerve Types

  • Sensory → Temperature & Proprioception

  • Motor → Strength & Normal Structure

  • ANS → Skin Lubrication & Blood Floow

What is pes cavus, and what pressure can result from it?

• Pes Cavus → High Arch + Rearfoot IV

  • Pressure On: Calcaneous & Met Heads

What are the primary hallux deformities?

• Hallux Valgus → Medial 1st Met + Lateral Big Toe

• Hallux Limitus / Hallux Rigidus → 1st MTP ROM Loss

What are the primary toe deformities?

• Hammer Toe → 2nd PIP FLX Contracture

• Claw Toe → 2nd-5th PIP + DIP FLX

What are typical s/sx of neuropathic ulcers?

• Location: Plantar Surface v Toes

• Pale Pink / Red

• Periwound Callus

• Minimal Drainage

• May Be Painless

• May Have Pulse

What is Charcot Foot?

• “Rocker Bottom” Deformation

  • Midfoot & Forefoot Disintegration

  • Rare Condition, Seen w/ DM

How are neuropathic wounds classified?

0. No Open Wounds, But High Risk

1. Ulcer Not Exposing SubQ

2. Ulcer Exposing SubQ

3. Abscess w/ Osteomyelitis

4. Partial Gangrene / Necrosis

5. Full Gangrene / Necrosis

What is the best way to assess sensory vibration?

• 128 Hz Tuning Fork At Great Toe >10 Seconds

What is the best way to assess sensory pressure?

• Semmes-Weinstein Monofilament Testing

What are typical gait deviations for DM patients?

• Wide BOS

• Early Heel Rise

• Decreased Cadence

• Decreased Step Length

• Prolonged Stance Phase

What are indications of a Total Contact Cast?

• Any Forefoot Ulcer

• Grade 1-2 Wagner Ulcers

• Early Charcot Foot

What are contraindications of a Total Contact Cast?

• Infection

• Severe Edema

• Arterial Disease

• Deep Wounds

How often should Total Contact Casts be changed?

• Weekly / Biweekly Dependent On Drainage

What are pros and cons of walking splints (compared to TCC)?

• Pros: Easily Removable

• Cons: Not As Good Relief

If casts or splints are too cumbersome, what is an alternative?

• Off-Loading Devices