Download - 1362465385 managinig neuropathic ulcer skke
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Daily Foot ExaminationDaily Foot Examination• Check For:Check For:
• BlistersBlisters• BleedingBleeding• InjuryInjury• SmellSmell• Increased temperature at pressure pointIncreased temperature at pressure point
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Management of Neuropathic Management of Neuropathic
Ulcer - 1Ulcer - 1
– General measures General measures
– Specific measuresSpecific measures
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Management of Neuropathic Management of Neuropathic
Ulcer - 2Ulcer - 2• Good glycemic controlGood glycemic control
• Treatment of infectionsTreatment of infections
• Management of neuropathic oedemaManagement of neuropathic oedema
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Management of Neuropathic Management of Neuropathic
Ulcer - 3Ulcer - 3• All ulcers irrespective of their cause will All ulcers irrespective of their cause will be slow to heal in presence of oedema, be slow to heal in presence of oedema, due impairment of local flowdue impairment of local flow
• Neuropathic oedema can be treated Neuropathic oedema can be treated with with – DiureticsDiuretics– Ace inhibitors Ace inhibitors – Ephedrine ( 30 mg tds )Ephedrine ( 30 mg tds )– D/d: hypoalbuminemia cardiac D/d: hypoalbuminemia cardiac
failurefailure
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Management of Neuropathic Management of Neuropathic
Ulcer - 4Ulcer - 4• ““Over 90% of predominantly Over 90% of predominantly
neuropathicneuropathic• ulcers will heal satisfactorily withulcers will heal satisfactorily with• conservative measures”conservative measures”
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Management of Neuropathic Management of Neuropathic
Ulcer - 5Ulcer - 5• ““Key to the management is the relief ofKey to the management is the relief of• pressure that caused the initial lesion”pressure that caused the initial lesion”• Pressure is off loaded most effectively byPressure is off loaded most effectively by• encasing the foot in a light plaster of encasing the foot in a light plaster of
parisparis• cast.cast.
– *Total contact cast*Total contact cast– *Removable scotch cast boot, *Removable scotch cast boot,
custom made shoes etc.custom made shoes etc.
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• You can put almost anything on the You can put almost anything on the ulcer except the patients weight – ulcer except the patients weight – says the Australian Podiatristsays the Australian Podiatrist
Management of Neuropathic Management of Neuropathic
Ulcer - 6Ulcer - 6
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Foot at risk - 1Foot at risk - 1• Our job – look after “NDF at risk”Our job – look after “NDF at risk”• A: Preventive measuresA: Preventive measures
•Treatment - rapid and intensiveTreatment - rapid and intensive•RestRest•Off loadOff load•AntibioticsAntibiotics•Foot wearFoot wear•Patient educationPatient education
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Foot at Risk - 2Foot at Risk - 2• B. Metabolic controlB. Metabolic control
– HyperglycemiaHyperglycemia– HypertensionHypertension– HyperlipidaemiaHyperlipidaemia– Cessation of smokingCessation of smoking
• C. Deformity managementC. Deformity management• D. Callus managementD. Callus management• E. Debridement and dry skin and fissureE. Debridement and dry skin and fissure• managementmanagement
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Foot at risk - 3Foot at risk - 3• F. Mechanical controlF. Mechanical control
– Off load, Off load, Off loadOff load, Off load, Off load•by rest, crutches, walkers, protective shoes, by rest, crutches, walkers, protective shoes,
heel protective pad, decrease plantar heel protective pad, decrease plantar pressure by removal calluspressure by removal callus
• G. The importance of callus removal in NFUG. The importance of callus removal in NFU•decrease plantar pressuredecrease plantar pressure•shows full dimension of the ulcershows full dimension of the ulcer•deep swab possibledeep swab possible•drainage of exudate, removal of dead tissuedrainage of exudate, removal of dead tissue
• H. Infection controlH. Infection control• I. Educational control I. Educational control
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Acute Chronic
Assess Assess vascular StatusVascular status
A/B index > 0.7Peripheral pulses A/B Index Assess Extent
weak / not palpable > 0.7 of InfectionA/B index < 0.5
Localised wound Deeper Inf. No Charcot Charcot FootColour Doppler CT Scan
Conservative Treatment Dedridement on Rule out MRI Complete restAngiography Anatomical Principles Osteomyelitis Nuclear plaster cast
scan antibioticsRevascularization Revacularization Dressing Contact Surgery
not feasible off loading cast CT. off loadingStrict & POP cast
Surgery Angioplasty Gene Therapy Higher Amputation Rehab Reconstruction off loading Till stage ofFootwear dressing reformation
Ischaemic painNo ischaemic pain Prolonged Gradual
antibiotic cover MobilisationStrict off loading
Gradual Foot wearAuto amputation Mobilisation restricted
ActivityFoot wear
SURGICAL TREATMENT OF
Assess Neuropathy
Rule out Charcot Foot
WOUND
DIABETIC FOOTBy Dr. Arun Bal
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Preventing Neuropathic Foot Preventing Neuropathic Foot Ulcers - 1Ulcers - 1• Regular inspection of foot - annuallyRegular inspection of foot - annually• Identification of high risk feet – 3 Identification of high risk feet – 3
mo / 6momo / 6mo• Careful choice of foot wearCareful choice of foot wear• Regular chiropodyRegular chiropody• Intense educationIntense education
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Preventing neuropathic foot Preventing neuropathic foot ulcers - 2ulcers - 2• “ “As little as one hour’s education As little as one hour’s education
provided by the podiatrist resulted in provided by the podiatrist resulted in 70% reduction in amputations over 70% reduction in amputations over the following 2 years . as compared the following 2 years . as compared with a control group who did not with a control group who did not receive the advice”receive the advice”
Malone IM et al 1989Malone IM et al 1989
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Glycemic control and Glycemic control and diabetic neuropathydiabetic neuropathy
• Diabetes control and complication Diabetes control and complication trialtrial
• showed that intensive insulin therapyshowed that intensive insulin therapy• reduced the incidence of appearance reduced the incidence of appearance
of of • neuropathy by about 70%neuropathy by about 70%
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Daily Foot ExaminationDaily Foot Examination• Check For:Check For:
• BlistersBlisters• BleedingBleeding• InjuryInjury• SmellSmell• Increased temperature at pressure pointIncreased temperature at pressure point
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Management of Neuropathic Management of Neuropathic
Ulcer - 1Ulcer - 1
– General measures General measures
– Specific measuresSpecific measures
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Management of Neuropathic Management of Neuropathic
Ulcer - 2Ulcer - 2• Good glycemic controlGood glycemic control
• Treatment of infectionsTreatment of infections
• Management of neuropathic oedemaManagement of neuropathic oedema
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Management of Neuropathic Management of Neuropathic
Ulcer - 3Ulcer - 3• All ulcers irrespective of their cause will All ulcers irrespective of their cause will be slow to heal in presence of oedema, be slow to heal in presence of oedema, due impairment of local flowdue impairment of local flow
• Neuropathic oedema can be treated Neuropathic oedema can be treated with with – DiureticsDiuretics– Ace inhibitors Ace inhibitors – Ephedrine ( 30 mg tds )Ephedrine ( 30 mg tds )– D/d: hypoalbuminemia cardiac D/d: hypoalbuminemia cardiac
failurefailure
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Management of Neuropathic Management of Neuropathic
Ulcer - 4Ulcer - 4• ““Over 90% of predominantly Over 90% of predominantly
neuropathicneuropathic• ulcers will heal satisfactorily withulcers will heal satisfactorily with• conservative measures”conservative measures”
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Management of Neuropathic Management of Neuropathic
Ulcer - 5Ulcer - 5• ““Key to the management is the relief ofKey to the management is the relief of• pressure that caused the initial lesion”pressure that caused the initial lesion”• Pressure is off loaded most effectively byPressure is off loaded most effectively by• encasing the foot in a light plaster of encasing the foot in a light plaster of
parisparis• cast.cast.
– *Total contact cast*Total contact cast– *Removable scotch cast boot, *Removable scotch cast boot,
custom made shoes etc.custom made shoes etc.
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• You can put almost anything on the You can put almost anything on the ulcer except the patients weight – ulcer except the patients weight – says the Australian Podiatristsays the Australian Podiatrist
Management of Neuropathic Management of Neuropathic
Ulcer - 6Ulcer - 6
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Foot at risk - 1Foot at risk - 1• Our job – look after “NDF at risk”Our job – look after “NDF at risk”• A: Preventive measuresA: Preventive measures
•Treatment - rapid and intensiveTreatment - rapid and intensive•RestRest•Off loadOff load•AntibioticsAntibiotics•Foot wearFoot wear•Patient educationPatient education
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Foot at Risk - 2Foot at Risk - 2• B. Metabolic controlB. Metabolic control
– HyperglycemiaHyperglycemia– HypertensionHypertension– HyperlipidaemiaHyperlipidaemia– Cessation of smokingCessation of smoking
• C. Deformity managementC. Deformity management• D. Callus managementD. Callus management• E. Debridement and dry skin and fissureE. Debridement and dry skin and fissure• managementmanagement
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Foot at risk - 3Foot at risk - 3• F. Mechanical controlF. Mechanical control
– Off load, Off load, Off loadOff load, Off load, Off load•by rest, crutches, walkers, protective shoes, by rest, crutches, walkers, protective shoes,
heel protective pad, decrease plantar heel protective pad, decrease plantar pressure by removal calluspressure by removal callus
• G. The importance of callus removal in NFUG. The importance of callus removal in NFU•decrease plantar pressuredecrease plantar pressure•shows full dimension of the ulcershows full dimension of the ulcer•deep swab possibledeep swab possible•drainage of exudate, removal of dead tissuedrainage of exudate, removal of dead tissue
• H. Infection controlH. Infection control• I. Educational control I. Educational control
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Acute Chronic
Assess Assess vascular StatusVascular status
A/B index > 0.7Peripheral pulses A/B Index Assess Extent
weak / not palpable > 0.7 of InfectionA/B index < 0.5
Localised wound Deeper Inf. No Charcot Charcot FootColour Doppler CT Scan
Conservative Treatment Dedridement on Rule out MRI Complete restAngiography Anatomical Principles Osteomyelitis Nuclear plaster cast
scan antibioticsRevascularization Revacularization Dressing Contact Surgery
not feasible off loading cast CT. off loadingStrict & POP cast
Surgery Angioplasty Gene Therapy Higher Amputation Rehab Reconstruction off loading Till stage ofFootwear dressing reformation
Ischaemic painNo ischaemic pain Prolonged Gradual
antibiotic cover MobilisationStrict off loading
Gradual Foot wearAuto amputation Mobilisation restricted
ActivityFoot wear
SURGICAL TREATMENT OF
Assess Neuropathy
Rule out Charcot Foot
WOUND
DIABETIC FOOTBy Dr. Arun Bal
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Preventing Neuropathic Foot Preventing Neuropathic Foot Ulcers - 1Ulcers - 1• Regular inspection of foot - annuallyRegular inspection of foot - annually• Identification of high risk feet – 3 Identification of high risk feet – 3
mo / 6momo / 6mo• Careful choice of foot wearCareful choice of foot wear• Regular chiropodyRegular chiropody• Intense educationIntense education
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Preventing neuropathic foot Preventing neuropathic foot ulcers - 2ulcers - 2• “ “As little as one hour’s education As little as one hour’s education
provided by the podiatrist resulted in provided by the podiatrist resulted in 70% reduction in amputations over 70% reduction in amputations over the following 2 years . as compared the following 2 years . as compared with a control group who did not with a control group who did not receive the advice”receive the advice”
Malone IM et al 1989Malone IM et al 1989
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Management involves Management involves • Bed restBed rest• Pressure offloadingPressure offloading• Reduction of edemaReduction of edema• Glycemic controlGlycemic control• Most important step is the early detectionMost important step is the early detection• of a high risk foot by simple tests / fewof a high risk foot by simple tests / few• quantitative testsquantitative tests