Foot and Leg Wound Management - Divisions of Family Practice

Report
Dr. Todd Yip MSc MD FRCPC
Dine and Learn Event
Victoria Division of Family Practice
January 28, 2014
Declaration
 One Bracing is an orthotic, bracing, and splinting
office within Rebalance MD clinic
Foot and Leg Ulcer Clinic
 RJH Memorial Pavilion
 40-50 new referrals per month
 Nurses, Pedorthist, Orthotist, Physician, Surgeon
 Not open Mondays, some Friday PM
 Referrals must be via Central Intake
 Recommend fax copy of referral to FLUC
Dr. Todd Yip MSc MD FRCPC
Victoria Division of Family Practice
Dine and Learn Event
January 28, 2014
Edema
 Lower limb edema control is vital to heal wounds and
to prevent recurrent ulceration.
 How much compression would be reasonable?
 What is a reasonable to compression management?
PVD Work-up
 Arterial
 **Renal function (eGFR >60)
 **Resting arterial doppler U/S (includes ABI)
 ABI (with doppler study
 **CTA Abdo Aorta + runoff (preferred)
 Conventional unilateral angiogram
 MR Angiography
 **key items
 Venous
 Reflux (valve competence)

Deep veins, Superficial veins, perforators
Ankle Brachial Index/Doppler
Ultrasound

Index






<0.4
Severe disease (rest pain)
0.4-0.9
Mild to moderate disease
0.9-1.2
Normal
>1.3
Poorly compressible vessels
Age and diabetes – main confounders
Doppler

Waveform (flattens with disease)




Normal
Mild disease
Severe disease
Localizes occlusive disease


Triphasic
Biphasic
Monophasic
Eg. Monophasic popliteal, dorsalis pedis,
posterior tibial = above knee stenosis
Toe pressure

>30 mmHg


Predicts healing in non-diabetic
>50 mmHg

Predicts healing in diabetic
Ankle Brachial Index
 Sensitivity: 70-90%
 Lower in elderly or diabetics
 Specificity: 65-95%
 Khan TH et al. Critical Review of the Ankle Brachial
Index. Current Cardiology Reviews, 2008, 4, 101-106
ABI/Toe Pressure
ABI/Toe Pressure
Approach to Compression
 Avoid compression (generally)
 Severe PAD; ABI <0.4
 Low compression (8-15 mmHg)
 ABI >0.5
 Pure venous + leg edema +/- significant drainage

Needs dressing, not socks
 Mixed PVD
 Medium compression (15-20 mmHg)
 Mixed PVD, if edema control reasonable
 If tolerating low compression
 Try adding low compression sock to low compression
dressing to graduate
Approach to Compression
 High compression
 At least 20-30 mmHg compression
 Strong, palpable pulses, normal ABI; No risk factors
 Pure venous disease, mild edema
 ?Local dressing + compression sock vs. compression
dressing
 Depends on clinical picture/practical options
 Trial and (hopefully not) error approach
 If dressings, change 2 to 3 x per week
Practical Considerations
 The application of compression dressings (or complex




dressing) is highly variable
Socks must be hand-washed and hung to dry
Socks must be less than 6-8 months old (of total daily
use)
Socks on in the AM, off in the PM, unless patient
sleeps in chair
Dressing and sock costs are often not covered in
community
Some Compression Dressings
 Modified Unna’s boot +/- tensor


Less than 10mmHg
Light options: local dressing + tubifast (blue- or yellow-line, or
tubigrip)
 Coban 2 lite – 20-30 mmHg
 Coban 2 – 30-40 mmHg
Some Compression Options
 If no ulcer or nearly healed, then compression
stockings:
 8-15 mmHg (e.g. “Diabetic sensifoot”)
 15-20 mmHg intermediate
 20-30 mmHg venous insufficiency, some PAD
 30-40 mmHg lymphedema
 40-50 mmHg young venous insufficiency
 Some patients can use remarkably high compression
safely
Compression Stocking Practical
Tips
 Layered lower level compression stockings for





increased compliance/ease of management and cost
savings
10 mmHg stocking liner
10 mmHg ankle-high “socklet”
Open-toed or zippered socks
Sock donning gadgets
Home supports as required for dressing
Dr. Todd Yip MSc MD FRCPC
Victoria Division of Family Practice
Dine and Learn Event
January 28, 2014
Work-up - Foot
 X-ray +/- x-ray in 3 weeks
 CBC, CRP, renal function
 Bone scan (debatable role – non-specific)
 “add infection label if +”


WBC label if <3/12
Gallium if >3/12
 Indicate duration of ulcer and if patient on antibiotics
on requisition
 MRI - ?debatable role
 Wound cultures can be helpful or misleading
Infection
 Legs
 Mostly clinical diagnosis

?Cellulitis vs. ?Stasis dermatitis vs. ?Ostemyelitis
 Essentially the same work up as feet
Diabetic Foot Infections (DFI)
 Mostly polymicrobial
 Aerobic GPC, especially staphylococci
 Aerobic GNB, if chronic
 Anaerobes, if ischemic or necrotic
 Foul odour of necrosis +/- pseudomonas
Reasonable Empiric Antibiotics
 1st line
 Keflex (500 mg BID-QID)
 Clindamycin (300-600 mg TID)
 2nd line
 Clindamycin + cipro (250-500 mg OD-BID)
 Clavulin (500 mg TID/875 mg BID)
 If MRSA
 Clindamycin, Bactrim (1 DS tab BID), or Doxycycline (100 mg
BID)
 Note: clindamycin requires no adjustment for renal
function and covers MRSA!
Parenteral Antibiotics
 Suggested Indications
 Failed oral antibiotics
 Abscess or ?abscess (surgical consult pending)
 Sepsis
 Dialysis
 Side effects from oral antibiotics
 Impaired immune response
 Past response of frequent flyers
 ?Non-adherence to oral medications?
 “No data support the superiority of any specific antibiotic agent
or treatment strategy, route, or duration of therapy”
 Lipsky et. al., 2012 Infectious Diseases Society of America Clinical
Practice Guideline for the Diagnosis and Treatment of Diabetic Foot
Infections. Clinical Infectious Diseases 2012;54(12):132-173
Imaging for Osteomyelitis Details
Modality
Sensitivity
(%)
Specificity
(%)
X-ray
43 to 75
65 to 83
Bone scan
69 to 100
38 to 82
25 to 80
67 to 85
90
80 to 90
82 to 100
75 to 96
Technetium-99m methylene diphosphonate
Gallium-67 citrate scan
WBC Scan
Technetium-99m hexamethyl-propyleneamine oxime-labeled
MRI
Pineda C, Vargas A, Rodriguez AV. Imaging of osteomyelitis: current concepts. Infect Dis Clin North
Am. 2006;20(4):789–825.
Termaat MF, Raijmakers PG, Scholten HJ, Bakker FC, Patka P, Haarman HJ. The accuracy of diagnostic
imaging for the assessment of chronic osteomyelitis: a systematic review and meta-analysis. J Bone Joint
Surg Am. 2005;87(11):2464–2471.
Kapoor A, Page S, Lavalley M, Gale DR, Felson DT. Magnetic resonance imaging for diagnosing foot
osteomyelitis: a meta-analysis. Arch Intern Med. 2007;167(2):125–132
Dr. Todd Yip MSc MD FRCPC
Victoria Division of Family Practice
Dine and Learn Event
January 28, 2014
Skin Manifestations of Diabetes
 Type 1
 Periungal telangiectasia
 Necrobiosis lipoidica
diabetacorum
 Bullosis diabeticorum
 Vitiligo
 Lichen ruber planus
 Type 2
 Yellow nails
 Diabetic thick skin
 Acrochordons (skin tags)
 Diabetic dermopathy

Skin spots and pigmented
pretibial papules
 Acanthosis nigricans
 Acquired perforating
dermatosis
 Calciphylaxis
 Eruptive xanthoma
 Granuloma annulare
Skin Manifestations of Drugs
 A number of reactions, too many to list
 Van hattem, Bootsma AH, Thio HB. Cleveland Clinic
Journal of Medicine: 75(11): 772-787
Three Recent Cases
My Main Differential Diagnosis
 Dry skin (autonomic)
 Fungus/tinea
 ??Psoriasis
 ??Something else that responds to topical steroid
 If psoriasis, then it is recommended not to debride
 So, confirming a diagnosis will affect the treatment
approach (i.e. it affects management)
?Psoriasis
 Usually 2-3 referrals per to Dr. Telford, RJH Psoriasis




Clinic dermatologist for “?Psoriasis not previously
diagnosed?”
For estimated >95% of referrals, Dr. Telford agrees
psoriasis – may or may agree with foot involvement
Prevalence = 2-4% general population
Prevalence among patients with diabetes?
Disclaimer: Dr. Telford’s consultation is pending for
these cases.
Recent Literature:
Psoriasis-Diabetes Link
 Independent risk factor in the development of T2DM
 Population-based cohort study (n=108132)
 HR 1.14 (mild psoriasis); 1.30 (severe psoriasis)

Arch Dermatol. 2012;148(9):995-1000.
 Associated with an increased prevalence and incidence of
diabetes
 Systematic review and meta-analysis
 27 Cohort, case-control, and cross-sectional studies from
1980-2012
 Prevalence OR 1.59 (1.97 if severe psoriasis); Incidence RR 1.27

JAMA Dermatol. 2013; 149(1)84-91.
Questions
 Is the reverse true?
 That is,
 Is the incidence and prevalence of psoriasis higher
amongst those with diabetes?
 Is diabetes and independent risk factor for psoriasis?
 Is psoriasis more prevalent among those with “severe”
diabetes? Or, those who have or at high risk of foot
ulcers?
Three Recent Cases
Simple Treatment Approach
 If unsure, consider treat with least
potentially harmful agent first
 Moisturizer


Hydrophilic petrolatum
Atrac-Tain
 Anti-fungal


Anti-dandruff shampoo foot wash
Lamisil 1% OD
 Steroid ointment

Clobetasol 0.05% OD (affected
areas only)
 Dermatology referral

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