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

• Recognizing and    • Diabetic Foot Care
  treating foot       • Examination
  conditions your     • Recommendations

  own setting        • Ulceration
• When to refer to   • Infections
  the foot folk      • Other tootsie
• Expanding your       issues
  own practice       • Elective surgeries
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
• 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
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?
Risk Factors for Ulceration/Amputation           (1)

• Peripheral sensory          • Smoking
  neuropathy:                 • Lower extremity
  #1 cause of ulceration        edema
• Structural foot deformity   • Uncontrolled
• Improperly fitting shoes      hyperglycemia
• History prior               • Vision
                              • Chronic Renal Disease
• Prolonged elevated
  pressures                   • Limited joint mobility
• Obesity                     • Poor blood flow
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:
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
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
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
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.
• Wounds probes to bone, unable to debride deeply
  d/t pain.
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
Case #2
• No admit. Will restart wound vac, abx regimen is
• Labs are trending down
• Albumin is too low so Wound Vac company denies
• 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?
Ulcer Treatment Guidelines                                       (2)

• Debridment of necrotic                • Medical management
  tissue                                  • Good glycemic control
  • Surgical, Mechanical, Autolytic,      • Good blood pressure
• Pressure Reduction                      • Renal status
  • Healing sandals, contact casting,
    offloading                          • Reduce the risk of
• Wound care                              recurrence
  • Dressings, Hygiene                    • Regular podiatric care
• Infection Control                       • Education
  • Cover MRSA if no culture taken,       • Protective footwear
    r/o osteomyelitis (xray vs MRI)??
• Vascular
  • Palpable pulses
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
 • 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
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….
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
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
  •   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.
Hierarchy of appropriate footwear for persons with diabetes (in order of
degree of specialization and cost)

Level 1: Quality walking or tennis shoes: Usually the most affordable and best-
looking option; some shoe manufacturers offer extra-large toe boxes and extra-
wide sizes to accommodate a wide range of foot shapes
Level 2: Off-the-shelf diabetic shoes with cushioned plantar inserts†Similar to
the above but provide additional room for inserts
Level 3: Custom prescriptions added to off-the-shelf diabetic shoes†Can
include rocker bottom soles, lifts, cutouts, wedges, or metatarsal bars to
accommodate deformities and provide for off-loading
Level 4: Customized molded diabetic shoes†Individually molded to
accommodate deformities; often unsightly in appearance
Level 5: Charcot restraint orthotic walkers (CROW boots)†Injection-molded
clamshell-type ìspace bootsî that accommodate extreme deformities and
instabilities and have approximately 11⁄-inch-thick rocker bottom soles ultimate
in protective diabetic footwear
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
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
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
• Onychogryphosis: ram’s horn nails
Elective Surgery
•   Bunions, Hammertoes, Plantar Fasciitis, etc
•   E-Referral to Podiatry
•   If ankle/rear foot complaints (except PF) refer to orthopaedic
• Ganglions
• Lipomas
• Melenoma
1. Armstrong DG, Lavery LA, Diabetic Foot
   Ulcers; Prevention, Diagnosis and
   Classification. American Family Physician.
   1998; March 15.
2. Rivera, Nancy, Diabetic Foot. Advance for
   Nurse Practitioners. 2009; 7:24-29.
3. 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.

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