1362465385 managinig neuropathic ulcer skke (1)

11

Daily Foot ExaminationDaily Foot Examination• Check For:Check For:

• BlistersBlisters• BleedingBleeding• InjuryInjury• SmellSmell• Increased temperature at pressure pointIncreased temperature at pressure point

22

Management of Neuropathic Management of Neuropathic

Ulcer - 1Ulcer - 1

– General measures General measures

– Specific measuresSpecific measures

33


Ulcer - 2Ulcer - 2• Good glycemic controlGood glycemic control

• Treatment of infectionsTreatment of infections

• Management of neuropathic oedemaManagement of neuropathic oedema

44


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

55


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”

66


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.

77

• 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


Ulcer - 6Ulcer - 6

88

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

99

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

1010

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

1111

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

1212

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

1313

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

1414

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%

1515

Daily Foot ExaminationDaily Foot Examination• Check For:Check For:

• BlistersBlisters• BleedingBleeding• InjuryInjury• SmellSmell• Increased temperature at pressure pointIncreased temperature at pressure point

1616


Ulcer - 1Ulcer - 1

– General measures General measures

– Specific measuresSpecific measures

1717


Ulcer - 2Ulcer - 2• Good glycemic controlGood glycemic control

• Treatment of infectionsTreatment of infections

• Management of neuropathic oedemaManagement of neuropathic oedema

1818


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

1919


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”

2020


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.

2121

• 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


Ulcer - 6Ulcer - 6

2222

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

2323

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

2424

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

2525

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

2626

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

2727

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

2828

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

Health & Medicine

1362465385 managinig neuropathic ulcer skke (1)