FACTSFACTS - EHOB · FACTSFACTS Pressure ulcers are ... –Tibia –Fibula 42 Bones of the Ankle and Foot ... compensate for a bone deformity, deforming forces, or forces absent from

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A Team Approach to Wound Care

on the Lower LimbA Physical Therapist’s Perspective

James G. Spahn, MD, FACS

Sharon Lucich, PT , CWS

Jaimee Haan, PT, CWS

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FACTSFACTS

Pressure ulcers are the result of an

ischemic event, and not a crush injury

Soft tissue distortion leads to

Ischemic necrosis (pressure ulcer).

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FACTSFACTS

Contact with a support surface causes

either volumetric support of the body or

distortion of the soft tissue trapped

between the bony prominence and the

support surface.

Since the body is three-dimensional,

volumetric support (flotation) is

needed to maintain proper tissue

orientation.

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2

FACTSFACTS

Nutritionally and mobility impaired

patients are at risk for developing

pressure ulcers.

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FACTSFACTS

Pressure ulcers may start immediately,

but often are not recognized until 3-7

days later.

High incidence of pressure ulcers may

occur on bed, surgery, ER, transportation

cart, and seating surfaces.

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FACTSFACTS

Continuum of care is needed during

the acute, sub-acute, and chronic

levels of care.

Patients at risk are usually discharged

to rehab, since they are not

rehabilitated at time of discharge.

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FACTSFACTS

Protocols decrease incidence by 50% 1

Usage of pressure-reducing devices

alone can cause an increase in

incidence.2

1. Moody BL, Fanale JE, Thompson M. Vaillancourt D, Symonds G, Bonasoro C. Impact of staff

education on pressure sore development in elderly hospitalized patients. Archives of Internal

Medicine. 1988; 148:2241-2243.

2. Lyder CH, Preston J, Grady JN, Scinto J, Allman R, Bergstrom N, Rodeheaver G. Quality of care

for hospitalized medicare patients at risk for pressure ulcers. Archives of Internal Medicine. 2001;

161: 1549-1544.

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Clinical Protocols

NutritionMobilization

Ambulate

TurnPassive Range of Motion

Support SurfaceBed, Chair, Cart, Emergency Room, Operating Room

Incontinence CareWound CareContinuum of Care

Treatment of other generalmedical conditions

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FACTSFACTS

Heel ulcers constitute 30% of all

pressure ulcers in hospital settings.

The heel consistently ranks as the

second most common location for

pressure ulcers.

Acute care heel prevalence is between

8-17% (1992)

15-23% (1997)

(Dekeyser, Dejarger, Meyst and Evers, 1994)

(Barczak, Barnett, Childs, Bosley, 1997)

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4

FACTSFACTS

Heel ulcers constitute 30% of all

pressure ulcers in hospital settings.

The heel consistently ranks as the

second most common location for

pressure ulcers.

Acute care heel prevalence is between

8-17% (1992)

15-23% (1997)

(Dekeyser, Dejarger, Meyst and Evers, 1994)

(Barczak, Barnett, Childs, Bosley, 1997)

What’s Wrong With This Picture?

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Hospital Bed Simulation

Pressure = 19mmHg

(3” high density foam, air mattress and bed. Clothing)

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5

13

60

50

40

30

20

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New Pressure UlcersIschial Tuberosity

Heel

Board 2” Foam 3” Foam 4” Foam Static

Air

Air on

FoamStrain % on Various Surface Type

50.1

10

4244

8.5

24.525.1

11.3

31.1

25

10.1

27.9

83

11.7

8

1.2

10.5

Greater Trochanter

Source: “Hospital Replacement

Mattresses.” “Journal of ET Nursing.”

Johnson, Daily & Franciscus.

Heel

Greater

Trochanter

Ischial Tuberosity

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Criteria for lower extremity protectionCriteria for lower extremity protection

In a horizontal In a horizontal postionpostion::

1.1. Provide volumetric support of calfProvide volumetric support of calf

(circulation)(circulation)

2.2. Protect skin (address bony Protect skin (address bony

prominences)prominences)

3.3. Maintain skeletal integrity (Maintain skeletal integrity (footdropfootdrop

& lateral rotation)& lateral rotation)

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Remember!RememberRemember!

No support surface by itself

adequately protects the heel

at all times.

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The Effects of Extended BedrestThe Effects of Extended Bedrest(Microgravity)

blood volume

in red cell mass

in muscle strength and work capacity

in maximum cardiac output

Loss of calcium, phosphate, and mass

from bones

“Most of these same effects also

occur in people who lie in bed for an

extended period of time.”

Guyton AC, Hall JE, Textbook of Medical Physiology.

Philadelphia: Saunders; 1996, p. 555.

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Mobility Rating

Self Mobility

Assisted Mobility

Active Range of Motion

Passive Range of Motion

Immobility

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NeutralNeutral

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Venous

Dependency

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10

28

29

30

11

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Contouring Static Air

(Flotation)Contouring Solid

(Distortion)

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Maintain Skeletal Integrity

Foot Drop

Lateral Rotation

Fractures

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Foot Risk AwarenessFoot Risk Awareness

Peripheral vascular

Contracture of leg

Deformity of foot

Skin viability

Shape of heel

Arterial

Venous

General health

Durability

No Yes

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Foot Risk AwarenessFoot Risk Awareness

Mobility of patientMobility of patient

+

=

Foot Risk assessment scaleFoot Risk assessment scale

Mobility of patientMobility of patient

Ambulatory

Ambulatory with assistance

Non-ambulatory

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Clinical Protocols

Nutrition

Mobilization

Support Surface

Incontinence Care

Wound Care

Continuum of Care

Treatment of other general medical conditions

Ambulate

Turn

Passive Range of Motion

Bed, Chair, Cart, Emergency Room, Operating Room

Lower Extremity

Protection

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Product Should:

Elevate heel (Dewedge)

Protect sides of foot and ankle

Neutralize weight of lower extremity (Delever)

Maintain and promote circulation

Address foot drop and lateral rotation of ankle

Allow access to the foot for

inspection/treatment

Facilitate the musculoskeletal pump

Fulfill regulatory requirements

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Physical Therapy Physical Therapy Perspective on Ankle Foot Perspective on Ankle Foot

OrthosisOrthosis (AFO’s)(AFO’s)

JaimeeJaimee HaanHaan, PT CWS, PT CWS Sharon Lucich, PT CWSSharon Lucich, PT CWS

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Basic Anatomy of the Basic Anatomy of the Lower ExtremityLower Extremity

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General General TerminologyTerminology

•• Dorsal:Dorsal: (Dorsum)(Dorsum)–– Top of the footTop of the foot

•• Plantar: Plantar: –– Bottom of the footBottom of the foot

•• Medial:Medial:–– Towards midlineTowards midline

•• Lateral: Lateral: –– Away from midlineAway from midline

•• Proximal: Proximal: –– Nearer to the trunk Nearer to the trunk

•• Distal:Distal:–– Farther away from the trunkFarther away from the trunk Moore, K, Dalley, A: Clinically Oriented Anatomy, 5th Ed., 2006

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Bones of the LegBones of the Leg

• Hip

– Pelvis

– Femur

• Thigh

– Femur

• Lower Leg

– Tibia

– Fibula

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Bones of the Ankle and FootBones of the Ankle and Foot

Hoppenfeld, Stanley: Physical Examination of the Spine and Extremities, 1976

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Main Muscles of the LegMain Muscles of the Leg

ANTERIOR:ANTERIOR:

• Knee extensors

– Quadriceps Femoris

•• Ankle Ankle DorsiflexorsDorsiflexors

– Anterior Tibialis

– Extensor Hallicus Longus

– Extensor Digitorum Longus

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Main Muscles of the LegMain Muscles of the Leg

POSTERIOR:POSTERIOR:

•• Hip extensorsHip extensors–– Gluteus Gluteus MaximusMaximus (Buttock )(Buttock )

•• Knee flexors Knee flexors (Hamstrings)(Hamstrings)

–– Biceps Biceps FemorisFemoris

–– SemitendonosusSemitendonosus

–– SemimembranosusSemimembranosus

•• Ankle Ankle PlantarflexorsPlantarflexors

–– GastrocnemiusGastrocnemius

–– SoleusSoleus

–– Achilles TendonAchilles Tendon

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Biomechanics of the Lower Biomechanics of the Lower ExtremityExtremity

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Joint MotionJoint Motion

• Range of Motion: (ROM)

– The amount of motion available at a joint

• Active Range of Motion (AROM):

– Amount of motion available at a joint by a

subject during unassisted voluntary

movement

• Passive Range of Motion (PROM):

– Amount of motion available at a joint attained

by an examiner without the assistance of the

subject

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• Goniometry:

– Measurement of joint

angles created by the

bones of the body

• Goniometer:

– Tool used for

goniometry

0o

45o

Knee ROM

30o

0o

Ankle ROM

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ROM of the HipROM of the Hip

• Flexion:

– Bending of the hip joint

• Extension:

– Straightening of the hip

Joint

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• Abduction:

– Movement of the femur away

from midline

• Adduction:

– Movement of the femur

towards midline

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• External (or Lateral) Rotation:– Rotation of the femur away

from midline

• Internal (or Medial) Rotation:– Rotation of the femur toward

midline

• Neutral Position: – No internal or external rotation

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ROM of the KneeROM of the Knee

• Flexion:

– Bending of the knee

• Extension:

– Straightening of the kneeHoppenfeld, Stanley: Physical Examination of the

Spine and Extremities, 1976

Hyperextension:Knee extension beyond

neutral

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Common Types of Knee Common Types of Knee DeformityDeformity

• Genu Varum:

• Genu Valgum:

• Genu Recurvatum:

Hoppenfeld, Stanley: Physical Examination of the Spine and Extremities, 1976

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ROM of the Foot and AnkleROM of the Foot and Ankle

• Plantarflexion:

– Ankle joint flexion

– Movement of the bottom of

the foot in the caudal (tail)

and posterior direction

• Dorsiflexion:

– Ankle joint extension

– Movement of the top of the

foot in the cranial (head)

and anterior direction

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ROM of the Foot and ROM of the Foot and AnkleAnkle

• Abduction:

– Movement in a sideways

direction away from

midline of the foot

• Adduction:

– Movement in a sideways

direction towards midline

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• Pronation:

– Rotation of the foot so that the sole of the foot faces a lateral (away from midline of the body) direction

• Supination:

– Rotation of the foot so that the sole of the foot faces a medial (toward midline of the body) direction

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• Inversion:

– A combination of

supination and

adduction of the foot

• Eversion:

– A combination of

pronation and

abduction

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Ankle AlignmentAnkle Alignment

• Neutral Position:– The ankle is considered to be

“in neutral” when the foot is at a right angle with the tibia

• Subtalar Neutral:– The point at which the

subtalar joint is fully supinated and then carried two-thirds of the way through maximum pronation

Relevance: when positioning a foot in a splint Relevance: when positioning a foot in a splint the goal is to achieve neutral alignment of the the goal is to achieve neutral alignment of the ankle and the ankle and the subtalarsubtalar jointjoint

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Gait Cycle

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Standing Alignment and Standing Alignment and BalanceBalance

Base of Support

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Phases of Gait CyclePhases of Gait CycleSTANCE PHASE SWING PHASE

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Abnormal Gait PatternsAbnormal Gait Patterns

• Foot slap

– Weak dorsiflexors

cause foot to slap

down

– Occurs at the

beginning of heel

strike

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• Toe scuff

– Lack of dorsiflexion

– Occurs during midswing

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Abnormal Gait Patterns

• High steppage gait

– Loss of dorsiflexion

– Inability to decelerate

dorsiflexors

– Knee lifts higher than normal

to allow foot to clear the floor

– Occurs during midswing

• Leg Length discrepancy ?

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• Hip hike

• Leg Length discrepancy?

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• Balance issues

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Common Foot/Ankle Common Foot/Ankle

Impairments Requiring the Impairments Requiring the

Use of an AFO Use of an AFO

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Foot DropFoot Drop

•• An abnormal neuromuscular An abnormal neuromuscular condition of the lower leg and condition of the lower leg and foot characterized by an inability foot characterized by an inability to to dorsiflexdorsiflex or or evertevert the footthe foot

•• May be due to damage to the May be due to damage to the Common Common PeronealPeroneal Nerve or Nerve or dorsiflexorsdorsiflexors

•• AFO can be used for treatment if AFO can be used for treatment if surgery not an optionsurgery not an option

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Foot Drop Foot Drop (cont)(cont)

• Splinting Philosophy

– Stabilize ankle in neutral position to maintain

functional ankle range of motion to allow

standing and ambulation (walking)

– Provide medial and lateral stabilization of the

hip joint (Use stabilization bar if available on

the AFO)

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Plantarflexion Contracture

• Abnormal, usually permanent, condition of the ankle joint characterized by plantarflexion and fixation; caused by atrophy and shortening of muscle fibers (“heel cord”)

• Goal: Maintenance of current ROM to enable adequate skin care and functional use

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SpasticitySpasticity

• A state of increased muscular tone with

exaggeration of tendon reflexes

• Common in patients with closed head

injuries, spinal cord injuries, cerebral palsy

or stroke

• Can cause deformity and limit functional

movement

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Spasticity Spasticity (cont)(cont)


– Apply mechanical force to correct or prevent

contractures

• Shortened muscles cause increased muscle tone;

splinting at the ankle puts the gastroc/achilles on a

prolonged stretch allowing lengthening to occur in

the collagen of the soft tissue and re-form to the

appropriate length

– Provides sensory stimulation which alters

muscle tone to promote normal movement

patterns

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Spasticity (cont)


– Precautions

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Plantar FasciitisPlantar Fasciitis

• Repetitive micro-trauma to Plantar Fascia (fibrous band that supports the arch of the foot)

• Causes pain on plantar surface of heel and medial aspect of foot with weight bearing

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Heel Pressure UlcerHeel Pressure Ulcer

• Development of a wound due to

mechanical stresses: pressure,

shear

• Prevention/Treatment

– Supports the ankle while a patient is

confined to bed for prolonged periods

of time decreases the risk of heel

breakdown

– Prevents prolonged pressure and

shear forces of the heel moving across

the bed

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General Splinting

Terminology and

Techniques

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Common TerminologyCommon Terminology

• Splint:

– An orthopedic device for immobilization,

restraint, or support of any part of the body

• Orthosis:

– A force system designed to control, correct, or

compensate for a bone deformity, deforming

forces, or forces absent from the body

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Traditional OrthoticsTraditional Orthotics

• Posterior leaf spring AFO

• Patellar-tibia bearing AFO

• Floor reaction AFO

• Conventional AFO

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Traditional Orthotics

• Foot or Shoe Orthotic (Insole)– Diabetics

– Pronated/Supinated foot

• Hinged ankle foot orthosis

• Rigid ankle foot orthosis

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Rigid Ankle Foot Rigid Ankle Foot OrthosisOrthosis (AFO)(AFO)

• Static Splints

– Immobilize

– Help prevent further

deformity

– Help prevent

contractures

Heel Heel PresurePresure Relieving Ankle Relieving Ankle

Foot Foot OrthosisOrthosis (AFO)(AFO)

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Heel Heel PresurePresure Relieving Ankle Relieving Ankle

Foot Foot OrthosisOrthosis (AFO)(AFO)

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Splinting (AFO) PrecautionsSplinting (AFO) Precautions

• Fit

– An ill-fitting ankle-foot orthosis can cause harm to the patient

– The ankle joint should be positioned in the splint at the correct therapeutic angle

– When a patient wears an AFO with padding in supine (lying on their back), the distal tibia is elevated relative to the proximal tibia and femur; This encourages knee hyperextension

– Signs of improper fit: skin redness, edema (swelling), joint stiffness, pain, skin rash, decreased circulation

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• Skin Assessment

– The clinician should don the AFO properly and leave in place for 20-30 minutes

– Red areas should not be present 20 minutes after removal of AFO

– Educate patient/family to report any rashes or other skin reactions

• Edema Assessment

– If AFO straps are applied too tight, issues with edema above and below straps may result and can cause skin breakdown.

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• Timing

– Splint schedules should be provided and patient,

family and education regarding splint schedule should

be provided

• Compliance

– Education of all parties involved in the patient’s care

is key to increasing patient compliance

– Education should include explanation of the goal of

wearing the splint, and should be repetitive and

consistent

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Splint ScheduleSplint Schedule

Please wear the splint according to the following schedule:

Day: 2 hours on, 2 hours off

Night: On all night

Special Instructions:

Contact Name/Number:

Precautions: redness, pain, swelling, rash or reduced sensation

8am-10am OFF

10am-12pm ON

12pm-2pm OFF

2pm-4pm ON

4pm-6pm OFF

6pm-8pm ON

8pm-10pm OFF

10pm-8am ON ALL

NIGHT

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HCPCS Code: L4398HCPCS Code: L4398Foot Drop Splint/Recumbent Positioning DeviceFoot Drop Splint/Recumbent Positioning Device

• A prefabricated ankle-foot orthosis

which has all of the following

characteristics:

– Designed to maintain the foot at a fixed

position of 0 degrees; and,

– Not designed to accommodate an ankle

with a plantarflexion contracture; and,

– Used by a patient who is nonambulatory;

and,

– Has a soft interface

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HCPCS Code: L4396HCPCS Code: L4396Static AFOStatic AFO

• Prefabricated ankle-foot orthosis which

has all of the following characteristics:

– Designed to accommodate either plantar

fasciitis or an ankle with a plantarflexion

contracture up to 45 degrees; and

– Applies a dorsiflexion force to the ankle; and,

– Used by a patient who is minimally

ambulatory, or nonambulatory; and,

– Has a soft interface

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Medicare ReimbursementMedicare Reimbursement

for HCPCS code L4396for HCPCS code L4396 (Static AFO)(Static AFO)

• Covered if all criteria 1-4 met or if criterion 5 is met

1. Plantarflexion contracture (718.47) with passive dorsiflexion of at least 10 degrees (non-fixed); and,

2. Reasonable expectation of ability to correct contracture; and,

3. Contracture interfering with functional abilities; and,

4. Used as component of therapy program which includes active stretching

5. Plantar fasciitis (728.71)

• For plantarflexion contracture:

– Pre-treatment PROM must be measured w/ goniometer and documented

– There must be documentation of stretching program carried out by professional or caregiver

– Reimbursement denied for• Fixed contracture

• Footdrop without an ankle flexion contracture

• A component of a static AFO that is used to address positioning of knee or hip because effectiveness has not been established

Evaluation of patient, measurement and fitting of orthosis are included in the

allowance for the orthosis. There is no separate payment for these services

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Other Medicare Reimbursement Other Medicare Reimbursement

CodesCodes

•• L1930 L1930 Plastic SplintPlastic Splint

•• L2820 L2820 Soft interfaceSoft interface

• L4360, L4386 Walking boot

• L4396 Static AFO

• L4398 Foot drop splint/recumbent

positioning device

• L4392 Replacement interface

• GY modifier must be added if AFO used solely for treatment of

edema and/or for prevention or treatment of a pressure ulcer

• Must indicate why e.g. “used to treat pressure ulcer”

Instead of L4396

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Questions??Questions??

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Thank You!Thank You!

Jaimee Haan, PT, CWS [email protected]

Sharon Lucich, PT, CWS [email protected]

Documents

FACTSFACTS - EHOB · FACTSFACTS Pressure ulcers are ... –Tibia –Fibula 42 Bones of the Ankle and Foot ... compensate for a bone deformity, deforming forces, or forces absent from