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76 Cards in this Set
- Front
- Back
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Risks for LEA (lower extremety amputation)
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Foot ulceration increases the risk for LEA, as well as, proteinuria, smoking, age, duration of diabetes, neuropathy, retinopathy and men
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What are the chances of a diabetic who undergoes LEA to have a contrlateral LEA within 5 yrs?
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50-70 %
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What 4 professionals does a diabetic need?
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MD, DO, NP, dietician, ophthalmologist, podiatrist, dentist
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What % of diabetics have significant neuropathy on gross PE?
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35%
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How does the loss of myelinated and nonmyelinated nerves usually progress?
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In a glove and stocking pattern
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What are the 3 types of neuropathy ?
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autonomic, sensory and motor
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How does an ulcer develop on a neuropathic foot?
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Abnormal pressures develop on the insensate foot
Because they can’t feel it, repetitive trauma and abnormal pressures Delay in treatment because they can’t feel it |
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Motor neuropathy
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Intrinsic muscle imbalance: deformity (hammertoes, clawtoes, plantarflexed metatarsals)
Increases pressure on ball of foot, toes, and heels |
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Autonomic neuropathy
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Skin temperature and sweating: dry, stiff skin
AV shunting making hyperemia difficult: ulceration |
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Charcot Neuroarthropathy
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1-2.5% of diabetics will develop it
Rapid onset of painless and severe joint destruction associated with fractures and dislocation. Erythema and Swelling. Non infectious. Usually seen in patients who have had the disease >10 years Pathogenesis is repetitive stress with limited sensation. Autonomic neuropathy plays a role Most common in midfoot and ankle. |
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What differentials need r/o in a Charcot foot?
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Must differentiate from cellulitis, osteomyelitis, gout
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What is the goal in a charcot foot?
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Goal is to make a shoeable, plantargrade, and stable foot and ankle
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If a foot is ulcerated what is the gold standard of treatment?
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total contact cast is gold standard,
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Common types of infections in the diabetic foot
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Infections are usually Staph (MRSA), Strep, Pseudomonas, Enterococcus, gram negative, and anaerobic.
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What ATB tx should be started?
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Start with empiric (Augmentin, Clindamycin, Omnicef, etc)
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The exam of the diabetic foot
History |
Must have a good one
Difficulty controlling sugars What meds are they on, how long have they had DM Smoking? Steroids? Sores that don’t heal? How long Claudication, vascular insufficiency Shoegear, bracing, previous ulceration |
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The exam of the diabetic foot
Neurological exam |
Neurological Exam: Must test for neuropathy
5.07 Semmes Weinstein: protective sensation Dry skin, loss of nails, intrinsic muscle wasting, sweating abnormalities, ulceration Light touch, two-point discrimination, pin prick may not show sensory neuropathy as will the monofilament |
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The exam of the diabetic foot
Vascular Exam |
Vascular Exam: mandatory for DM with ulcers
Pulses, doppler, digital plethsmography Pulse volume recordings, Ankle brachial index Transcutaneous oxygen, angiography Calcification on X-rays Loss of hair, thin skin, pallor on trendelenberg, thickened nails Claudication Diabetics are 4X as likely to have to have arterial occlusive disease |
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The exam of the diabetic foot
Deformities |
Look for callouses (preulcerative)
Hammertoes, clawtoes, mallet toes Bunions, midfoot collapse Severe cavus foot types, bony prominences Look at their shoes (seams, straps, buckles, laces) Do they have accommodative diabetic inserts and extra depth shoes. |
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What is the most often injured joint in the body?
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The ankle
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What 3 ligaments groups support the ankle?
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medial, lateral, and interosseous
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What is the most typical sprain of the ankle?
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inversion sprains
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most commonly injured of lateral ligaments
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anterior talofibular (ATF),
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a clue to “high” ankle sprains or bony involvement
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Rotation (external)
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Diagnosis of Ankle Sprains
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Pain over ligaments, examine high fibula
Swelling, ecchymosis (loss of anatomical landmarks) Unable to bear weight History of twisting or turning ankle Previous sprains Must rule out bony pathology Positive anterior drawer, squeeze, or talar tilt test |
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Classification of ankle sprains
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Grade I: stretching
Grade II: partial tear Grade III: complete |
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Treatment of
Ankle Sprains |
Early protected mobilization increases ROM, tensile strength of ligaments
RICEN with protected weightbearing (aircast or air-stirrup, unna boot) if no medial or syndesmotic injury Medial injury or syndesmotic injury delays recovery Severe instability, swelling and pain may need to be casted and non-weightbearing or partial weightbearing Rehabilitation of proprioceptive fibers, strengthening of muscles, and ROM a MUST!! Especially in the athlete Cam-Walker or fracture walker Prevention Bracing, taping High top shoes |
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When to refer
Ankle Sprains |
Any fracture
“High” ankle sprains (syndesmotic injury) Medial injuries People not making progress or no improvement over 4-6 week course of treatment Chronic sprainers Suspicious injuries (tendon, subluxations) Severe injury |
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Also referred to as Heel Pain Syndrome, Heel Spur Syndrome
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Plantar Fasciitis
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What Really Happens in plantar fasciitis
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Layered fibrous band
Medial tuberosity to digits Repetitive stress, tears, fatigue, inflammation, degeneration Similar event in FDB accounting for spur because of fatigue of fascia. |
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Signs and Symptoms
Plantar Fasciitis |
45 years old. F>M 2:1
H/O recent weight gain, activity or standing Insidious onset, worse with first few steps in a.m. or after sitting Pain usually resolves during the day and is aggravated by prolonged standing or activity Most common sight is at medial calcaneal tuberosity and proximal 1-2 cm of plantar fascia. Can be mid-arch (distal plantar fasciitis) which is not as common. Radiation is unusual!!!!! Must differentiate from other causes of heel pain |
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Treatment Modalities
Plantar Fasciitis |
90% respond to conservative treatment!!!!
Must modify to fit patient’s needs and lifestyle Athletes and weekend warriors are different! Geriatrics are also different Reduce the inflammation Stretch, Stretch, Stretch!!!!!! Improve shoe gear |
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When to Refer
Plantar Fasciitis |
Pain resistant conservative measures depending on how comfortable you are treating it
Foot biomechanical abnormality (pes planus- flat foot or pes cavus high arch) Suspected fracture, seronegative or positive disease, nerve entrapment Tx more than 8 weeks without relief |
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Digital Fractures Signs and Symptoms
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Pain and swelling
H/O trauma Ecchymosis Obvious displacement Must look for associated injuries like nail trauma |
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Differential Diagnosis for digital fx
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Gout, inflammatory arthritis (RA)
Cellulitis or infection; neuropathic joint X-ray will give diagnosis, take 2 to see displacement (DP and oblique or lateral) |
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Treatment
for digital fx |
If no displacement: hard shoe and buddy tape or splint
If displaced, reduce it, then splint Ice, elevation, pain control 3-4 weeks in hard shoe until tenderness subsides |
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What type of fx usually occurs in the hallux?
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Usually direct trauma, all ages
Fx of distal phalanx is usually crushing injury |
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Signs and Symptoms
of hallux fx |
Same as lesser toes except on larger scale
Look for nail bed lacs PAINFUL!!!!! |
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Treatment
of hallux fx |
Same as lesser toes if not displaced
May need a BK cast May have to splint more aggressively Surgery if displaced or non-reducible, or open Kids may be affected These fractures cause sequelae if not properly treated |
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Sequelae
of hallux fx |
Arthritis, stiffness, loss of function
Bone spur or malalign-ment Mini-compartment syndrome (Hallux) Persistent pain Loss of digit |
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When to Refer hallux fx
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Open fractures, especially, the Hallux
Non-reducible fractures Significant trauma (associated fractures or nail bed damage) Intra-articular fractures of the Hallux |
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Onychomycosis
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Fungal infection of the nail
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Most common cause of Fungal infection of the nail
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Trichophyton rubrum, T. mentagrophytes, and Epidermophyton floccosum.
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Three types of Fungal infection of the nail
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distal subungual, proximal subungual, white superficial
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Signs and Symptoms
Distal Subungual |
Yellow, lysis, subungual debris, nail and nail bed thickening causing dystrophy
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Signs and Symptoms
Proximal Subungual |
nail plate infection, debris under nail, thickening, T. rubrum, loosening of nail
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Signs and Symptoms
Superficial White: |
invasion of superficial nail plate, soft, dry, powdery brittle, no thickening, no lysis, T. mentagrophytes
Thickened nail may cause pain May have Tinea Pedis |
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Signs and Symptoms
Onychomycosis |
Thickened or incurvated nails may “ingrow” into nail fold causing paronychia
May be a “harbor” for bacterial infection Very difficult to cut for patients when thickened and elongated |
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Differentials for
Onychomycosis |
Onychogryphosis: repetitive trauma
Skin disease: lichen planus, eczema, psoriasis, etc. Disease: carcinoma (Yellow nail syndrome clubbing) Infections: candidal, psuedomonas, staph |
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Diagnosis and Treatment
Onychomycosis |
Just by looking at the nail, it’s 50/50
Must take a fungal culture of nail Must watch out for underlying MELANOMA!! Diabetics may have several organisms May want to take a bacterial culture if suspicious (Diabetic with greenish thickened nail. |
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Onychomycosis Treatment
Topical: |
Penlac, Tineacide, Fungoid Tincture
Not very effective except Penlac Use in Superficial White disease Problem is penetration of nail plate Penlac: QD for 48 weeks |
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Onychomycosis Treatment Systemic:
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Sporonox, Lamisil, Diflucan
Sporonox: 200mg bid one week a month x3 months (Pulse Dose) Lamisil: 250 qd for 3 months Both can effect liver Liver enzymes? Sporonox a little more broad spectrum Lamisil more effective |
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Cause of warts
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Caused by a virus, Human Papilloma Virus
many serotypes, 1,2,4 are most common in foot |
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What are verrucae or warts?
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benign neoplasms confined to the epidermis
Contagious and transmitted usually in public areas (i.e. showers, pools, locker rooms) Many last under 2 years, however, some are very resistant |
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verrucae vulgaris
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Common warts:
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verrucae plantaris
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Planters warts:
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What specific serotypes of warts are assoiated with cancer?
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16 & 18
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Signs and Symptoms of warts
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Mostly in young people, however, adults can be infected
Firm papules with warty surface May coalesce to form Mosaic patches. There is association of very wet feet (hyperhydrosis) Are painful if in weight bearing areas Pinpoint bleeding when debrided May see dried hemorrhage from thrombosed capillaries Loss of skin lines Pain on lateral compression May occur at or under nail which can cause pain and dystrophy of the nail Can be flesh colored and crusty |
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differentials for warts
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Must differentiate other benign or malignant lesions
Intractable Plantar Keratosis Molluscum Contagiosum: Pox virus Hand-Foot-and Mouth Disease (Coxsackie) |
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Morton’s Neuroma
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Can happen to any of the plantar nerves but the fourth is most common because of the anatomy
Women are more commonly affected Tight, narrow shoes Also called interdigital neuritis |
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Morton’s Neuroma Signs and Symptoms
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Burning sensation in the 3rd and 4th toes
Focal parasthesias May be aggravated by certain shoes Feeling of walking on a “marble” or “lamp cord” Heels and narrow toe box aggravate Pain in webspace Mulder’s click Must examine metatarsal heads and ROM X-rays are usually normal but must take them to rule out bony pathology MRI and Ultrasound are useful adjuncts but are costly Diagnostic block in the interspace Metatarsals may be in close proximity to each other |
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Conservative Treatment
Morton’s Neuroma |
NSAIDS or injections
Shoe gear modifications and padding to splay metatarsals and off-load the nerve. Orthotics Ultrasound, iontophoresis, etc |
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Surgical Treatment
Morton’s Neuroma |
Removal of nerve and branches
Will be numb after surgery. Stump neuroma |
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When to refer
Morton’s Neuroma |
Continued pain
Associated deformity (instability of MPJ) When conservative measures fail Recurrence of symptoms is common Don’t blast them too much |
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Paronychia, Onychocryptosis, Uncus Incurnatus
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Ingrown Toenails
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Causes of ingrown toenails
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Hypertrophic labia
Subungual exostosis Congenital Trauma Fungal nails Excessively tight shoe Cutting nails to short |
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Treatments if ingrown toenails
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Soaks and antibiotics
Partial excision Permanent excision with chemicals or surgical methods |
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When to refer:
ingrown toenails |
Chronic ingrowns
Ingrowns that don’t resolve Permanent removals Ingrowns with advanced cellulitis |
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Gold Standard for diagnosis of OM
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Bone bx
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Do you have to have neuropathy to have Charcots?
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Yes
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How much redness in an infected foot should be present for pt to be admitted?
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> 2cm
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What will happen to a surgical incision if there is no blood flow to it?
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It will go gangreneous
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What are loss of hair, thin skin, pallor on trendelenberg, and thickened nails a sign of on a foot exam?
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Vascular insufficiency
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What is the usual dx for pain over ATF?
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Sprain
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When ordering xrays of digital fx how many veiws should you order?
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At least 2 views- AP/Lat
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Which plantar nerve is most affected by a Morton's neuroma?
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3rd plantar nerve
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