The Boot? Taking care of your patient’s toes in and out of primary care

1. The Boot?Taking care of your patient’s toes in and out of primary care Erica V. Eshoo, NP Department of Orthopaedics SFGH

2. http://www.youtube.com/watch?v=_m64cy1MMPg

3. Objectives Topics • Recognizing and treating foot conditions your own setting • When to refer to the foot folk • Expanding your own practice • Diabetic Foot Care • Examination • Recommendations • Ulceration • Infections • Other tootsie issues • Elective surgeries

4. 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

6. Diabetic Foot Care • Diabetic Foot Levels (1,2,3) • Examination • 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?

7. Risk Factors for Ulceration/Amputation (1) • Peripheral sensory neuropathy: #1 cause of ulceration • Structural foot deformity • Improperly fitting shoes • History prior ulceration/amputation • Prolonged elevated pressures • Obesity • Smoking • Lower extremity edema • Uncontrolled hyperglycemia • Vision • Chronic Renal Disease • Limited joint mobility • Poor blood flow

8. 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

12. 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

13. 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 deformity-ARF ulceration d/t biomechanical abnormality • ACUTE CHARCOT REQUIRES PROMPT REFERRAL

15. 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

18. 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.

20. 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

22. 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?

24. Ulcer Treatment Guidelines (2) • 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 • Medical management • Good glycemic control • Good blood pressure management • Renal status • Reduce the risk of recurrence • Regular podiatric care • Education • Protective footwear

25. Admission vs Outpatient? • An admission is determined by • 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 • Superficial to full thickness, no bone involved • Medically stable • Mild erythema, warmth, edema • In office sharps debridement, boney excision

26. 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 co-morbidities: renal, cardiac, endocrine….

35. 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

36. 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 • 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.

38. Is that a wart? • 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

40. Plantar Fasciitis • Inflammation and swelling in the thick tissue of the heel • WORSE in the morning! • Conservative treatment • 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

42. 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

46. Elective Surgery • Bunions, Hammertoes, Plantar Fasciitis, etc • Get WIEGHT-BEARING FILMS! • E-Referral to Podiatry • If ankle/rear foot complaints (except PF) refer to orthopaedic surgery

48. Masses • Ganglions • Lipomas • Melenoma

50. Sources • Armstrong DG, Lavery LA, Diabetic Foot Ulcers; Prevention, Diagnosis and Classification. American Family Physician. 1998; March 15. • Rivera, Nancy, Diabetic Foot. Advance for Nurse Practitioners. 2009; 7:24-29. • 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.