Considerations in Lower Extremity Wounds

1. Considerations in Lower Extremity Wounds Philip McKinney, DPM

2. Nothing to Disclose

3. Primary Consideration in LE Wounds • Peripheral neuropathy affecting the lower extremity becomes our primary deterrent to wound healing. Without tactile sensation there is no perception, without perception there is no pain. • Pain is God’s greatest gift to mankind. Paul Brand, MD

4. Paul Wilson Brand, MD (1914-2003) Began his work at the National Hansen’s Disease Center in Carville, Louisiana in 1965. A pioneer in surgery to reconstruct deformities of the hand and feet brought about by Hansen’s disease. It was his initial work in India that provided him with the understanding of the need to address the lack of pain in preventing the wounds from healing.

6. Cost-effectiveness Studies

7. Risk Factors for Ulceration Neuropathy Sensory Motor Autonomic Deformity( hammertoes, Bunion, Charcot ) Minor Trauma High plantar pressures Shoe pressure High impact Improper foot care Thermal injury Hot soaks Frostbite Limited Joint Mobility ( hallux limitus, equinus) Vascular Disease Macrovascular Microvascular Previous Ulceration Amputation Nephropathy Smoking Hyperglycemia

27. Equinus

29. Metatarsal head loading

31. Pressure plate loading with orthotic use.

32. Peak Pressure Reduction

33. Percentage/Days to healing

35. Charcot foot

37. Stairway to amputation

38. Off loading

43. Wound Assessment • Wound description ( color, slough, necrotic tissue) • Wound dimensions ( size, area, depth) • Probe for depth • Bone, sinus tracts • Determine presence of infection Culture as indicated • Assess for neuropathy Monofilament, vibration, two point discrimination • Vascularity Pulses, rubor, temperature Noninvasive tests ABI, Doppler, TcPO2 Angiography • Determine etiology • Classification Wagner University of Texas

44. Wagner Classification of Diabetic Foot Ulcers • Grade 0: No ulcer in a high risk foot. • Grade 1: Superficial ulcer involving the full skin thickness but not underlying tissues. • Grade 2: Deep ulcer, penetrating down to ligaments and muscle, but no bone involvement or abscess formation. • Grade 3: Deep ulcer with cellulitis or abscess formation, often with osteomyelitis. • Grade 4: Localized gangrene. • Grade 5: Extensive gangrene involving the whole foot.

45. University of Texas Wound Classification System • Grade I-A: non-infected, non-ischemic superficial ulceration • Grade I-B: infected, non-ischemic superficial ulceration • Grade I-C: ischemic, non-infected superficial ulceration • Grade I-D: ischemic and infected superficial ulceration • Grade II-A: non-infected, non-ischemic ulcer that penetrates to capsule or bone • Grade II-B: infected, non-ischemic ulcer that penetrates to capsule or bone • Grade II-C: ischemic, non-infected ulcer that penetrates to capsule or bone • Grade II-D: ischemic and infected ulcer that penetrates to capsule or bone • Grade III-A: non-infected, non-ischemic ulcer that penetrates to bone or a deep abscess • Grade III-B: infected, non-ischemic ulcer that penetrates to bone or a deep abscess • Grade III-C: ischemic, non-infected ulcer that penetrates to bone or a deep abscess • Grade III-D: ischemic and infected ulcer that penetrates to bone or a deep abscess

46. Factors influencing wound closure Wound Location Tissue extensibility/contracture Depth Size Exudate Bacterial colonization Arterial insufficiency Lymphedema Venous insufficiency Neuropathy Deformity Uncontrolled diabetes Equinus Hypertension Osseous structures Pervious infection Renal insufficiency Malnutrition Anemia Congestive Heart Tobacco Coronary artery disease Alcohol Obesity Drug use Compliance Functional status