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Wound Care and Diabetic Neuropathic Ulcer Cordell “Corky” Atkins PT, DPT, CWS, CDE, CPed

Wound Care and Diabetic Neuropathic Ulcer Cordell “Corky” Atkins PT, DPT, CWS, CDE, CPed. Intermountain Medical Center Salt Lake City, Utah. Objectives. Review the anatomy and physiology of the skin. Understand the cascade of wound healing.

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Wound Care and Diabetic Neuropathic Ulcer Cordell “Corky” Atkins PT, DPT, CWS, CDE, CPed

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  1. Wound Care and Diabetic Neuropathic Ulcer Cordell “Corky” Atkins PT, DPT, CWS, CDE, CPed Intermountain Medical Center Salt Lake City, Utah

  2. Objectives • Review the anatomy and physiology of the skin. • Understand the cascade of wound healing. • Present interventions for the care of the diabetic foot wound. • Review the research associated with wound healing and the diabetic foot.

  3. Glabrous skin Hairy skin Epidermis Meissner's corpuscles Hair shaft Epidermis Merkel's discs End-bulb of Krause Dermis Free nerve endings Ruffini end organ Dermis Pacinian corpuscle Hypodermis Vein Bone Artery Adipose tissue Connective tissue Erector pili muscle Hair folicle Sweat gland Muscle Sebaceous gland

  4. Epidermal layers Glabrous skin Hairy skin Stratum corneum Stratum lucidum Stratum granulosum Stratum corneum Stratum granulosum Stratum spinosum Stratum spinosum Stratum basal Stratum basal

  5. Epidermis • Prevents dehydration of other tissues • Protects from organism, toxins, mechanical injury and light. • Keep the nutrients in the skin • Responds to various stimuli

  6. Dermis • Provides Strength and elasticity to skin • Regulation of body temperature • Provides nourishment to the epidermis

  7. Subcutaneous Fatty Layer • Insulates • Provides support and cushion • Stores energy

  8. Anatomy • Hair Follicles-produce hair • Sweat Glands-produce sweat (cooling) • Apocrine-stress • Eccrine-thermoregulatory • Sebaceous Glands-produce sebum to keep hair and skin suppleNerve endings-pain, heat, cold, touch • Arteries and Veins-nutrients, O2, & waste • Lymph Vessels-remove excess fluid

  9. Phases of Wound Healing • Hemostasis • Inflammatory Phase • Proliferative Phase • Maturation Phase

  10. Hemostatis(5- 10 minutes) • Vasoconstriction • Vasodilation • Fibrin clot formation • Coagulation

  11. Clinical Activities Erythema Rubor Warmth Calor Edema Tumor Pain Dolor Cellular Activities Leukocyte migration Neutrophils Monocyte conversion Macrophages- PDGF--TGF-ß Inflammatory Phase(3-4 days)

  12. Clinical Activities Beefy red granulation Cellular Activities Macrophages-produce chemotactic and growth promoting substances for granulation and epithelialization Proliferative Phase(21 days)

  13. Clinical Activities Beefy red granulation Thin epithelial tissue around the red granulation tissue Wound Shrinkage Cellular Activities Collagen synthesis- Tensile strength Angiogenesis- Endothelial cell buds Epithelializaton – Keratinocyte migration Contraction- Fibroblasts change to Myofibroblasts Proliferative Phase(21 days)

  14. Clinical Activities Shrinking, thinning, paling of scar Cellular Activities Collagen(Type III to Type I) remodeling and capillary regression-fibroblasts leave wound, fibronectin eliminated, tensile strength increases Maturation Phase(12-18 months)

  15. Wound Healing • Moist • Warm • Clean

  16. Wound Not Healing • Dehydration • Reinjury • Hypergranulation • Maceration • Cooling

  17. Wound Needs • Proper Hydration • Thermal protection • Relief of necrotic tissue • Bacterial Control • Optimal pH

  18. Topical Management • Compression • Stockings • Wraps • Other

  19. Diabetes Mellitus • Diabetes mellitus consists of a group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion, insulin action, or both.

  20. Classification Type 1 Type 2 90% of individuals with diabetes Usually after age 40 Frequently asymptomatic- Not prone to ketosis Approximately 80% obese @diagnosis • Develops at any age but most before age 30 • Develop weight loss, polyuria, polydipsia with signs of marked hyperglycemia and strong propensity for ketoacidosis

  21. Complications • Retinopathy • Nephropathy • Neuropathy • Vascular changes • Atherosclerosis • Angiogenesis • DCCT N Engl J Med vol 329 • Follow- up Diabetes Care 2010 May;33(5) • UKPDS Lancet vol 352

  22. Diabetic Neuropathy • A demonstrable disorder, either clinically evident or subclinical, that occurs in the setting of diabetes mellitus without other causes for peripheral nervous system. Diabetes Care. 1988;11:592-597

  23. Neuropathy • Affects sensory, motor, autonomic nervous system • Underdiagnosed • Total costs - $37 billion • Type 1 and Type 2 DM pts at equal risk • Increases with time

  24. Peripheral Neuropathy • Tingling, burning, or prickling • Sharp pains or cramps • Extreme sensitivity to touch, even light touch • Numbness or insensitivity to pain or temperature • Loss of balance and coordination • Stocking Glove

  25. Motor Neuropathy • Intrinsic muscle weakness • Increase pull of long flexors

  26. Autonomic neuropathy • Autonomic sympathetic neuropathy causes vasodilation and decreased sweating resulting in warm overly dry feet → cracks and fissures → infection.

  27. CAUSAL PATHWAYS FOR FOOT ULCERS Neuropathy % Causal Pathways  Neuropathy: 78% Deformity Minor trauma: 79%  Deformity: 63% Minor Trauma Mechanical (shoes) Thermal Poor self foot Care Chemical Ulcer DiabetesCare 1999; 22:157

  28. Treatment Interventions • Off-loading • Debridement • Dressings • Management of Infection • Vascular reconstruction • Amputation Diabetes Care. 1999;8:1354-1360

  29. Hyperkeratosis at wound edges Hypertrophic dermis Less inflammatory cellular components Newly formed small vessels orienting from wound edges Replication of keratinocytes with migration to center of the wound Piaggesi A. et al, Diabetes Care. 2003 Nov; 26(11):3123-8 Benefits of Off-loading

  30. Repetitive StressBrand, 1982 used with permission of J Birke GWLHDC

  31. Control 2 days / 10,000 steps Weekends off / 7,000 steps 7 days / 10,000 steps used with permission of J Birke GWLHDC

  32. Off-loading Pressure • Total Contact Casting • Surgical Shoes • Half Shoes • Sandals • Felted Foam

  33. Pressure It's not what you put on, but what you take off… Armstrong, Lavery, CID, 2004: 39 (Supp 2) The Total Contact Cast is the Gold Standard But is not commonly used because of concerns about secondary injuries, inadequate skill/training and time constraints Armstrong, Lavery. Diabetes Care 2001: 24:1019-1022

  34. Debridement • Removal of devitalized, nonviable tissue to help the diabetic ulcer heal more rapidly • Surgical • Sharp Steed. J Am Coll Surg 1996; 183: 61–4.

  35. Dressings • Minimize further trauma • Minimized infection risk • Optimize environment • 9 Topical trials • Collagen, Gels, Foam, ORC Collagen, Cadexomer Iodine, Alginate, Sodium CMC

  36. Absorption Hydration Moisture Retention Conforms to Depth and contours Thermal Insulation Bacterial Barriers Active Bacterial Control Odor Control Adherence Dressing Benefits

  37. Infection Management • Clinical uninfected < 105org/gm • Non-limb-threatening -superficial • Limb-treatening -involving tendon, bone, capsule plus ischemia • Osteomyelitis –infected bone

  38. Infection • Increased bacterial count • 105 organism/gm of sample • Erythema (Rubor) • Warmth (Calor) Fever/Chills • Edema (Tumor) • Pain (Dolor) • Uncontrollable Blood Glucose • Drainage • Odor

  39. Vascular Reconstruction • Favorable results • Improved healing • Reduced pain • Improved function/mobility Hirsch AT, et al. /J Vasc IntervRadiol. 2006 Sep;17(9):1383-97

  40. Amputation • After extensive discussion • Treatment options • Level of choice • Contralateral limb

  41. Multidisciplinary Care • Patient and family • Physicians and surgeons • Nurse/Educators • Therapists • Social worker • Orthotists, prosthetists, pedorthitists • Others

  42. Modifications • Personal care • Activity limitations • Assistive devices • Gait • Irritations • Wound

  43. Repetitive walking stress is the most common mechanism of injury and faulty healing in the neuropathic foot. Brand 1982- Brand, 1982

  44. Cost Analysis of Ulcer Care • Medicare costs for patients with foot ulcers were • 3 times higher than for diabetes patients in • general. • Inpatient care accounted for 74% of diabetic • ulcer-related Medicare costs. • Any wound care intervention that reduces the • need for hospitalization should reduce costs. - Harrington, 2000

  45. Ulcer Management Wound CareOff-LoadingRemodelingProtective Footwear

  46. “The treatment of neuropathic foot ulcerations is (a matter of) mechanics not medicine”Dr. Paul W. Brand 1915-2003

  47. Insanity Is Continually Doing the Same Thing Expecting Different Results

  48. Thank you Cordell “Corky” Atkins PT, DPT, CWS, CDE, CPed Cordell.Atkins@imail.org Intermountain Medical Center Salt Lake City, Utah

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