The Boot?
Taking care of your
patient’s toes in and
out of primary care
Erica V. Eshoo, NP
Department of Orthopaedics
SFGH
http://www.youtube.com/watch?v=_m64cy
1MMPg
Objectives
• Recognizing and
treating foot
conditions your
own setting
• When to refer to
the foot folk
• Expanding your
own practice
Topics
• Diabetic Foot Care
• Examination
• Recommendations
• Ulceration
• Infections
• Other tootsie
issues
• Elective surgeries
Case Study #1
• 61 year old uncontrolled DM Female stepped on metal rake 2 weeks
ago, seen in ED and treated with Septra and Cipro x 1 week
• Has what looks like abscess, swelling, erythema, pain
• 3+ pitting edema left forefoot with erythema and increased
temperature. Yellow opaque exudate visible under the skin in the
fourth interspace, and appears to be tracking plantar medially to the
second interspace. Puncture wound visible under the 5th met head
area.
• WBC 13.4 with a left shift, ESR 92, CRP 51, Glucose 244
• X-ray: no evidence of osteomyelitis or Foreign Body
• Admission and I&D of left 4th interspace.
• IV antibiotics after culture sent: Vancomycin
• Discharged with PO Agumentin and woundcare
Diabetic Foot Care
• Diabetic Foot Levels (1,2,3)
• Examination
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•
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Vascular: discoloration, edema, claudication
Neurological: burning, tingling, numbness, balance
Dermatologic: calluses, scaling, dryness, reddened areas, thick nails
Musculoskeletal: foot deformity, flexibility, weakness
• Care
• Nails and Skincare
• Corns, calluses, fungus, elongated nails, ulcerations
• Shoe gear
• What are they wearing? How is it affecting their feet?
Risk Factors for Ulceration/Amputation
• Peripheral sensory
neuropathy:
#1 cause of ulceration
• Structural foot deformity
• Improperly fitting shoes
• History prior
ulceration/amputation
• Prolonged elevated
pressures
• Obesity
(1)
• Smoking
• Lower extremity
edema
• Uncontrolled
hyperglycemia
• Vision
• Chronic Renal Disease
• Limited joint mobility
• Poor blood flow
When to refer to the specialist
• Diabetic with only neuropathy: PCP management
• Diabetic with neuropathy, history of OR current ulceration,
foot deformities, nail anomalies, poor vision, poor circulation:
HAND THEM OVER !
• http://www.youtube.com/watch?v=RXx5LqB6ZnQ
How to help out the foot folk
• Suspected infection…
•
•
•
•
Open wound: tissue quality
Skin color: cellulitis, purulence, fluctuance
Edema
Vital Sings/abnormal labs
• Severity
• Send to ED and/or call ortho consult 719-2475
• call podiatry for advise/urgency of scheduling
• E-Referral if non-acute
• Order:
• Plain films, MRI NOT NECESSARY
• CBC with diff, Sed Rate, CRP, Complex Metabolic Panel
Neuropathic Osteoarthropathy
AKA Charcot
• Causes:
• Peripheral neuropathy
• Unrecognized trauma
• Inflammation
• Characteristics:
• Joint dislocation
• Pathological fractures
• Collapse of the foot and ankle
• Often misdiagnosed for acute cellulitis or sprain
• Chronic Charcot can cause rocker bottom deformityARF ulceration d/t biomechanical abnormality
• ACUTE CHARCOT REQUIRES PROMPT REFERRAL
Peripheral Vascular Disease
• Blood flow is IMPARATIVE to wound healing
• No blood flow…send em to gen surg/vascular
• High risk for gangrene and limb loss
• Diminished blood flow
• Moderate risk for gangrene
• Super slow healing of ulcerations
• Venous Stasis Ulcers / Arterial Ulcers
• Treatment
• Unna Boot
• Compression Stockings
• Vascular Consult CT angiogram with bilateral leg runoffs/ ABIs
Case Study #2
• 30 yr old IDDM with h/o ulceration, charcot, has
current ulceration
• Medically compromised: obesity, HD, anemia,
peripheral vascular disease
• Comes to clinic with 2 large plantar ulcers,
malodorous, recent multiple hospitalizations,
cellulitis, on oral abx.
• Labs: HIGH ESR, CRP
• Wounds probes to bone, unable to debride deeply
d/t pain.
Case study #2
• Return to wound clinic 2 days later with necrotic
fourth toe.
• Refuse admit here, wishes to go to another hospital
• Aortogram (patent vessels) and debridement of
ulcer and amputation of 4th toe
• Wound Vac and IV abx ordered
• Left AMA, ordered IV abx at dialysis and orals
• Malfunction wound vac, return to SFGH with deep
wound with tendon exposed
Case #2
• No admit. Will restart wound vac, abx regimen is
approved
• Labs are trending down
• Albumin is too low so Wound Vac company denies
request.
• Needs to get supplements at Dialysis, wound vac vs
packed woundcare
• Needs e-referral for HAH for wound vac changes-denies
due to ambulatory status
• Now what?
Ulcer Treatment Guidelines
• Debridment of necrotic
tissue
• Surgical, Mechanical, Autolytic,
Enzymatic
• Pressure Reduction
• Healing sandals, contact casting,
offloading
• Wound care
• Dressings, Hygiene
• Infection Control
• Cover MRSA if no culture taken,
r/o osteomyelitis (xray vs MRI)??
• Vascular
• Palpable pulses
(2)
• Medical management
• Good glycemic control
• Good blood pressure
management
• Renal status
• Reduce the risk of
recurrence
• Regular podiatric care
• Education
• Protective footwear
Admission vs Outpatient?
• An admission is determined by
•
•
•
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Extent of cellulitis
Vital Sign abnormality, abnormal labs
Lymphangiitis
Soft tissue necrosis, fluctuance, odor, gangrene, risk of
osteomyelitis
• I&D, boney excision, extent of infection: limb loss risk?
• Less threatening
•
•
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Superficial to full thickness, no bone involved
Medically stable
Mild erythema, warmth, edema
In office sharps debridement, boney excision
Infection….what are we treating?
• In our practice we treat a Diabetic with a non-identified
bacteria with a broad spectrum antibiotic that will cover for
osteomyelitis and MRSA
• Septra DS
• Clindamycin
• Once a specimen is obtained we then will change the
treatment plan if necessary
• Frequent office visits
• Helpful if PCP is involved with medical management with comorbidities: renal, cardiac, endocrine….
Wound Care- Where?
• 4C: frequent dressing changes under the watchful eyes of
Trish McCarthy and Ardene Ballonado NPs and the staff
• Can the patient do it?
• Back to Podiatry weekly/ q 2 weeks for sharps debridments
and reassessments until closure
Assistive Shoes/Braces-O&P!!
• Total Contact Cast
•
Indicated for offloading planter digit, planter metatarsal, medial metatarsal, lateral
metatarsal, charcot midfoot and heel wounds.
• Removable Cast Walker/ Walking Boots
•
Charcot Restraint Orthotic Walker (CROW) boot
•
•
Indicated for offloading planter digit, planter metatarsal, medial metatarsal, lateral metatarsal,
charcot midfoot,and heel wounds.
Bledso Boot
•
Indicated for limiting mobility of the foot/ankle
• Wedge Shoes
•
Darco Wedge Shoe
•
•
Indicated for offloading planter digit, planter metatarsal, medial metatarsal, and lateral metatarsal
wounds.
Darco Reverse Wedge Shoe
•
Indicated for offloading heel wounds.
• Multipodus Splint / Boot
•
Indicated for offloading heel and ankle wounds.
• Surgical Shoes or Shoes with Pressure Relief Insoles
•
Post op shoe
•
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Indicated for offloading dorsal digit wounds.
Plastizote Healing Shoe
•
Indicated for offloading the dorsal digit, planter digit, planter metatarsal, medial metatarsal, lateral
metatarsal, and heel wounds.
Hierarchy of appropriate footwear for persons with diabetes (in order of
degree of specialization and cost)
Level 1: Quality walking or tennis shoes: Usually the most affordable and bestlooking option; some shoe manufacturers offer extra-large toe boxes and extrawide sizes to accommodate a wide range of foot shapes
Level 2: Off-the-shelf diabetic shoes with cushioned plantar inserts†Similar to
the above but provide additional room for inserts
Level 3: Custom prescriptions added to off-the-shelf diabetic shoes†Can
include rocker bottom soles, lifts, cutouts, wedges, or metatarsal bars to
accommodate deformities and provide for off-loading
Level 4: Customized molded diabetic shoes†Individually molded to
accommodate deformities; often unsightly in appearance
Level 5: Charcot restraint orthotic walkers (CROW boots)†Injection-molded
clamshell-type ìspace bootsî that accommodate extreme deformities and
instabilities and have approximately 11⁄-inch-thick rocker bottom soles ultimate
in protective diabetic footwear
Is that a wart?
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•
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Form of HPV called Verucca Plantaris
Appears with tiny hemerrhages
Skin striae go around plantar warts
If not a wart, the skin striae go right through
Painful to squeeze test, unlike calluses that are
painful to direct pressure
• Treatment:
• Mediplast 40% patches, change daily, skin get macerated and wart
sloughs off
• Freezing
• Surgical Curettage
Plantar Fasciitis
• Inflammation and swelling in the thick tissue of the heel
• WORSE in the morning!
• Conservative treatment
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•
•
•
ICE
Stretch
Shoes at all times
NSAIDS
• Next Steps
• Custom orthotics (on site
• Bledso boot/casting
• Steroid Injections
• Last Resort
• Plantar Fasciotomy
• Heel Spur resection
Nail Fungus
• Onychomycosis: nail plate is thickened, yellow, or
cloudy appearance. The nails can become rough and
crumbly, or can separate from the nail bed
• Risk Factors: fam hx, age, poor health, warm temp
• Treatment:
• Debridment
• Econazole 1% cream, Clotrimazole 1% topical
• Oral: Lamicil 1 tab po q day x 3 months, Fluconazole 1 tab po q week
times 3 months…MUST CHECK LIVER, COST/INSURANCE
• Onychogryphosis: ram’s horn nails
Elective Surgery
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Bunions, Hammertoes, Plantar Fasciitis, etc
Get WIEGHT-BEARING FILMS!
E-Referral to Podiatry
If ankle/rear foot complaints (except PF) refer to orthopaedic
surgery
Masses
• Ganglions
• Lipomas
• Melenoma
Sources
1. Armstrong DG, Lavery LA, Diabetic Foot
Ulcers; Prevention, Diagnosis and
Classification. American Family Physician.
1998; March 15.
2. Rivera, Nancy, Diabetic Foot. Advance for
Nurse Practitioners. 2009; 7:24-29.
3. Frykberg, R, Armstrong, D, Giurini, J,
Edwards, A, Kravette, M, Kravits, S, Ross, C,
Stavosky, J, Stuck, R, Vanore, J, Diabetic Foot
Disorders, A clinical Practice Guideline. 2000.