Presentation on theme: "Foot and Leg Wound Management: Medical Issues"— Presentation transcript:
1 Foot and Leg Wound Management: Medical Issues Dr. Todd Yip MSc MD FRCPCDine and Learn EventVictoria Division of Family PracticeJanuary 28, 2014
2 DeclarationOne Bracing is an orthotic, bracing, and splinting office within Rebalance MD clinic
3 Foot and Leg Ulcer Clinic RJH Memorial Pavilion40-50 new referrals per monthNurses, Pedorthist, Orthotist, Physician, SurgeonNot open Mondays, some Friday PMReferrals must be via Central IntakeRecommend fax copy of referral to FLUC
4 Peripheral Vascular Disease and Compression Dr. Todd Yip MSc MD FRCPCVictoria Division of Family PracticeDine and Learn EventJanuary 28, 2014
5 EdemaLower 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?
7 Ankle Brachial Index/Doppler Ultrasound <0.4 Severe disease (rest pain)Mild to moderate diseaseNormal>1.3 Poorly compressible vesselsAge and diabetes – main confoundersDopplerWaveform (flattens with disease)Triphasic NormalBiphasic Mild diseaseMonophasic Severe diseaseLocalizes occlusive diseaseEg. Monophasic popliteal, dorsalis pedis, posterior tibial = above knee stenosisToe pressure>30 mmHgPredicts healing in non-diabetic>50 mmHgPredicts healing in diabetic
8 Ankle Brachial Index Sensitivity: 70-90% Specificity: 65-95% Lower in elderly or diabeticsSpecificity: 65-95%Khan TH et al. Critical Review of the Ankle Brachial Index. Current Cardiology Reviews, 2008, 4,
11 Approach to Compression Avoid compression (generally)Severe PAD; ABI <0.4Low compression (8-15 mmHg)ABI >0.5Pure venous + leg edema +/- significant drainageNeeds dressing, not socksMixed PVDMedium compression (15-20 mmHg)Mixed PVD, if edema control reasonableIf tolerating low compressionTry adding low compression sock to low compression dressing to graduate
12 Approach to Compression High compressionAt least mmHg compressionStrong, palpable pulses, normal ABI; No risk factorsPure venous disease, mild edema?Local dressing + compression sock vs. compression dressingDepends on clinical picture/practical optionsTrial and (hopefully not) error approachIf dressings, change 2 to 3 x per week
13 Practical Considerations The application of compression dressings (or complex dressing) is highly variableSocks must be hand-washed and hung to drySocks 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 chairDressing and sock costs are often not covered in community
14 Some Compression Dressings Modified Unna’s boot +/- tensorLess than 10mmHgLight options: local dressing + tubifast (blue- or yellow-line, or tubigrip)Coban 2 lite – mmHgCoban 2 – mmHg
15 Some Compression Options If no ulcer or nearly healed, then compression stockings:8-15 mmHg (e.g. “Diabetic sensifoot”)15-20 mmHg intermediate20-30 mmHg venous insufficiency, some PAD30-40 mmHg lymphedema40-50 mmHg young venous insufficiencySome patients can use remarkably high compression safely
16 Compression Stocking Practical Tips Layered lower level compression stockings for increased compliance/ease of management and cost savings10 mmHg stocking liner10 mmHg ankle-high “socklet”Open-toed or zippered socksSock donning gadgetsHome supports as required for dressing
17 Infection Dr. Todd Yip MSc MD FRCPC Victoria Division of Family PracticeDine and Learn EventJanuary 28, 2014
18 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 <3/12Gallium if >3/12Indicate duration of ulcer and if patient on antibiotics on requisitionMRI - ?debatable roleWound cultures can be helpful or misleading
19 Infection Legs Mostly clinical diagnosis ?Cellulitis vs. ?Stasis dermatitis vs. ?OstemyelitisEssentially the same work up as feet
20 Diabetic Foot Infections (DFI) Mostly polymicrobialAerobic GPC, especially staphylococciAerobic GNB, if chronicAnaerobes, if ischemic or necroticFoul odour of necrosis +/- pseudomonas
21 Reasonable Empiric Antibiotics 1st lineKeflex (500 mg BID-QID)Clindamycin ( mg TID)2nd lineClindamycin + cipro ( mg OD-BID)Clavulin (500 mg TID/875 mg BID)If MRSAClindamycin, Bactrim (1 DS tab BID), or Doxycycline (100 mg BID)Note: clindamycin requires no adjustment for renal function and covers MRSA!
22 Parenteral Antibiotics Suggested IndicationsFailed oral antibioticsAbscess or ?abscess (surgical consult pending)SepsisDialysisSide effects from oral antibioticsImpaired immune responsePast 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):
23 Imaging for Osteomyelitis Details ModalitySensitivity(%)SpecificityX-ray43 to 7565 to 83Bone scanTechnetium-99m methylene diphosphonate69 to 10038 to 82Gallium-67 citrate scan25 to 8067 to 85WBC Scan Technetium-99m hexamethyl-propyleneamine oxime-labeled9080 to 90MRI82 to 10075 to 96Pineda 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
24 Dermatology and Diabetes: Something Different? Dr. Todd Yip MSc MD FRCPCVictoria Division of Family PracticeDine and Learn EventJanuary 28, 2014
25 Skin Manifestations of Diabetes Type 1Periungal telangiectasiaNecrobiosis lipoidica diabetacorumBullosis diabeticorumVitiligoLichen ruber planusType 2Yellow nailsDiabetic thick skinAcrochordons (skin tags)Diabetic dermopathySkin spots and pigmented pretibial papulesAcanthosis nigricansAcquired perforating dermatosisCalciphylaxisEruptive xanthomaGranuloma annulare
26 Skin Manifestations of Drugs A number of reactions, too many to listVan hattem, Bootsma AH, Thio HB. Cleveland Clinic Journal of Medicine: 75(11):
31 My Main Differential Diagnosis Dry skin (autonomic)Fungus/tinea??Psoriasis??Something else that responds to topical steroidIf psoriasis, then it is recommended not to debrideSo, confirming a diagnosis will affect the treatment approach (i.e. it affects management)
32 ?PsoriasisUsually 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 involvementPrevalence = 2-4% general populationPrevalence among patients with diabetes?Disclaimer: Dr. Telford’s consultation is pending for these cases.
33 Recent Literature: Psoriasis-Diabetes Link Independent risk factor in the development of T2DMPopulation-based cohort study (n=108132)HR 1.14 (mild psoriasis); 1.30 (severe psoriasis)Arch Dermatol. 2012;148(9):Associated with an increased prevalence and incidence of diabetesSystematic review and meta-analysis27 Cohort, case-control, and cross-sectional studies fromPrevalence OR 1.59 (1.97 if severe psoriasis); Incidence RR 1.27JAMA Dermatol. 2013; 149(1)84-91.
34 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?