Wound Care and Diabetic Neuropathic Ulcer

Cordell “Corky” AtkinsPT, DPT, CWS, CDE, CPed

Intermountain Medical Center Salt Lake City, Utah

ObjectivesObjectivesReview the anatomy and physiology of Review the anatomy and physiology of

the skin.the skin.Understand the cascade of wound Understand the cascade of wound

healing.healing.Present interventions for the care of the Present interventions for the care of the

diabetic foot wound.diabetic foot wound.Review the research associated with Review the research associated with

wound healing and the diabetic foot.wound healing and the diabetic foot.

Epidermis

Hypodermis

Bone

Dermis End-bulbof Krause

Meissner'scorpuscles

Ruffiniend organ

Dermis

Epidermis

Artery

Vein

Merkel's discs

Hair shaft

Glabrous skin

Hairy skin

Free nerve endings

Pacinian corpuscle

Erector pilimuscle

Sweatgland

Sebaceousgland

Connectivetissue Hair

folicleMuscle

Adiposetissue

Epidermal layersEpidermal layers

Stratum basal

Stratum lucidum

Stratum spinosum

Stratum granulosum

Stratum corneum

Stratum basal

Stratum spinosum

Stratum granulosum

Stratum corneum

Glabrous skin Hairy skin

EpidermisEpidermisPrevents dehydration of other Prevents dehydration of other

tissuestissuesProtects from organism, toxins, Protects from organism, toxins,

mechanical injury and light.mechanical injury and light.Keep the nutrients in the skinKeep the nutrients in the skinResponds to various stimuliResponds to various stimuli

DermisDermisProvides Strength and elasticity Provides Strength and elasticity

to skinto skinRegulation of body temperatureRegulation of body temperatureProvides nourishment to the Provides nourishment to the

epidermis epidermis

Subcutaneous Fatty Subcutaneous Fatty LayerLayer

Insulates Insulates Provides support and Provides support and

cushioncushionStores energyStores energy

AnatomyAnatomyHair Follicles-produce hairHair Follicles-produce hairSweat Glands-produce sweat (cooling)Sweat Glands-produce sweat (cooling)

Apocrine-stressApocrine-stressEccrine-thermoregulatoryEccrine-thermoregulatory

Sebaceous Glands-produce sebum to keep hair Sebaceous Glands-produce sebum to keep hair and skin suppleNerve endings-pain, heat, cold, and skin suppleNerve endings-pain, heat, cold, touchtouch

Arteries and Veins-nutrients, OArteries and Veins-nutrients, O2,2, & waste & wasteLymph Vessels-remove excess fluid Lymph Vessels-remove excess fluid

Phases of Wound Healing

HemostasisHemostasisInflammatory PhaseInflammatory PhaseProliferative PhaseProliferative PhaseMaturation PhaseMaturation Phase

HemostatisHemostatis(5- 10 minutes)(5- 10 minutes)

VasoconstrictionVasoconstrictionVasodilationVasodilation Fibrin clot formationFibrin clot formation CoagulationCoagulation

Inflammatory PhaseInflammatory Phase(3-4 days)(3-4 days)

Clinical ActivitiesClinical ActivitiesErythema RuborErythema RuborWarmth CalorWarmth CalorEdema TumorEdema TumorPain DolorPain Dolor

Cellular ActivitiesCellular ActivitiesLeukocyte migrationLeukocyte migration

NeutrophilsNeutrophilsMonocyte conversionMonocyte conversion

Macrophages-Macrophages-PDGF--TGF-ßPDGF--TGF-ß

Proliferative PhaseProliferative Phase(21 days)(21 days)

Clinical ActivitiesClinical ActivitiesBeefy red Beefy red

granulationgranulation

Cellular ActivitiesCellular ActivitiesMacrophages-Macrophages-

produce produce chemotactic and chemotactic and growth promoting growth promoting substances for substances for granulation and granulation and epithelializationepithelialization

Proliferative PhaseProliferative Phase(21 days)(21 days)

Clinical ActivitiesClinical ActivitiesBeefy red granulationBeefy red granulationThin epithelial tissue Thin epithelial tissue

around the red around the red granulation tissuegranulation tissue

Wound ShrinkageWound Shrinkage

Cellular ActivitiesCellular ActivitiesCollagen synthesis- Collagen synthesis-

Tensile strengthTensile strength

Angiogenesis- Angiogenesis- Endothelial cell buds Endothelial cell buds

Epithelializaton – Epithelializaton – Keratinocyte migrationKeratinocyte migration

Contraction- Contraction- Fibroblasts change to Fibroblasts change to MyofibroblastsMyofibroblasts

Maturation PhaseMaturation Phase(12-18 months)(12-18 months)

Clinical ActivitiesClinical ActivitiesShrinking, Shrinking,

thinning, paling thinning, paling of scarof scar

Cellular ActivitiesCellular ActivitiesCollagenCollagen (Type III to (Type III to

Type I) Type I) remodeling remodeling and capillary and capillary regression-fibroblasts regression-fibroblasts leave wound, leave wound, fibronectin fibronectin eliminated, tensile eliminated, tensile strength increasesstrength increases

Wound HealingWound Healing

MoistMoistWarmWarmCleanClean

Wound Not HealingWound Not HealingDehydrationDehydrationReinjuryReinjuryHypergranulationHypergranulationMacerationMacerationCoolingCooling

Wound NeedsWound NeedsProper HydrationProper HydrationThermal protectionThermal protectionRelief of necrotic tissueRelief of necrotic tissueBacterial ControlBacterial ControlOptimal pHOptimal pH

Topical ManagementTopical ManagementCompressionCompression

StockingsStockingsWrapsWrapsOtherOther

Diabetes MellitusDiabetes MellitusDiabetes mellitus consists of a Diabetes mellitus consists of a

group of metabolic diseases group of metabolic diseases characterized by hyperglycemia characterized by hyperglycemia resulting from defects in insulin resulting from defects in insulin secretion, insulin action, or both.secretion, insulin action, or both.

ClassificationClassificationType 1Type 1

Develops at any age Develops at any age but most before age 30but most before age 30

Develop weight loss, Develop weight loss, polyuria, polydipsia polyuria, polydipsia with signs of marked with signs of marked hyperglycemia and hyperglycemia and strong propensity for strong propensity for ketoacidosisketoacidosis

Type 2Type 290% of individuals 90% of individuals

with diabeteswith diabetesUsually after age 40 Usually after age 40 Frequently Frequently

asymptomatic-asymptomatic- Not prone to ketosisNot prone to ketosis Approximately 80% Approximately 80%

obese @diagnosisobese @diagnosis

ComplicationsComplicationsRetinopathyRetinopathyNephropathyNephropathyNeuropathyNeuropathyVascular changesVascular changes

AtherosclerosisAtherosclerosisAngiogenesisAngiogenesis

DCCTDCCT N Engl J Med vol 329N Engl J Med vol 329

Follow- upFollow- up Diabetes Care 2010 May;33(5)Diabetes Care 2010 May;33(5)

UKPDS UKPDS

Lancet vol 352Lancet vol 352

Diabetic NeuropathyDiabetic NeuropathyA demonstrable disorder, either A demonstrable disorder, either

clinically evident or subclinical, that clinically evident or subclinical, that occurs in the setting of diabetes mellitus occurs in the setting of diabetes mellitus without other causes for peripheral without other causes for peripheral nervous system. nervous system.

Diabetes CareDiabetes Care. 1988;11:592-597. 1988;11:592-597

NeuropathyNeuropathyAffects sensory, motor, autonomic Affects sensory, motor, autonomic

nervous systemnervous systemUnderdiagnosedUnderdiagnosedTotal costs - $37 billionTotal costs - $37 billionType 1 and Type 2 DM pts at Type 1 and Type 2 DM pts at

equal riskequal riskIncreases with timeIncreases with time

Peripheral NeuropathyPeripheral Neuropathy Tingling, burning, or pricklingTingling, burning, or pricklingSharp pains or crampsSharp pains or crampsExtreme sensitivity to touch, even light Extreme sensitivity to touch, even light

touchtouchNumbness or insensitivity to pain or Numbness or insensitivity to pain or

temperaturetemperatureLoss of balance and coordinationLoss of balance and coordinationStocking GloveStocking Glove

Motor NeuropathyMotor NeuropathyIntrinsic muscle weaknessIntrinsic muscle weaknessIncrease pull of long flexorsIncrease pull of long flexors

Autonomic neuropathyAutonomic neuropathy

Autonomic sympathetic Autonomic sympathetic neuropathy causes vasodilation neuropathy causes vasodilation and decreased sweating resulting and decreased sweating resulting in warm overly dry feet → cracks in warm overly dry feet → cracks and fissures → infection. and fissures → infection.

CAUSAL PATHWAYS FOR FOOT ULCERSCAUSAL PATHWAYS FOR FOOT ULCERS

NeuropathyNeuropathy % Causal Pathways % Causal Pathways

Neuropathy: Neuropathy: 78% 78%

Deformity Deformity Minor trauma:Minor trauma: 79%79%

Deformity:Deformity: 63%63%

Minor Trauma Minor Trauma

Mechanical (shoes) Mechanical (shoes)

Thermal Thermal Poor self foot Care Poor self foot Care

ChemicalChemical

Ulcer Ulcer DiabetesDiabetes CareCare 1999; 22:157 1999; 22:157

Treatment InterventionsTreatment Interventions

Off-loadingOff-loadingDebridementDebridementDressingsDressingsManagement of InfectionManagement of InfectionVascular reconstructionVascular reconstructionAmputationAmputation

Diabetes CareDiabetes Care. 1999;8:1354-. 1999;8:1354-13601360

Benefits of Off-loadingBenefits of Off-loading Hyperkeratosis at wound Hyperkeratosis at wound

edgesedges Hypertrophic dermisHypertrophic dermis Less inflammatory cellular Less inflammatory cellular

componentscomponents Newly formed small vessels Newly formed small vessels

orienting from wound edgesorienting from wound edges Replication of keratinocytes Replication of keratinocytes

with migration to center of with migration to center of the woundthe wound

Piaggesi A. et al, Piaggesi A. et al, Diabetes Care. 2003 Nov; Diabetes Care. 2003 Nov; 26(11):3123-8 26(11):3123-8

Repetitive StressRepetitive StressBrand, 1982Brand, 1982

used with permission of J Birke GWLHDC

ControlControl 2 days / 10,000 steps2 days / 10,000 steps

7 days / 10,000 steps7 days / 10,000 steps Weekends off / 7,000 stepsWeekends off / 7,000 stepsused with permission of J Birke

GWLHDC

Off-loading Pressure Off-loading Pressure

Total Contact CastingTotal Contact CastingSurgical ShoesSurgical ShoesHalf ShoesHalf ShoesSandalsSandalsFelted FoamFelted Foam

PressurePressureIt's not what you put on, but what It's not what you put on, but what

you take off…you take off… Armstrong, Lavery, CID, 2004: 39 (Supp 2)Armstrong, Lavery, CID, 2004: 39 (Supp 2)

The Total Contact Cast is the Gold The Total Contact Cast is the Gold StandardStandard

But is not commonly used because of concerns about secondary But is not commonly used because of concerns about secondary injuries, inadequate skill/training and time constraintsinjuries, inadequate skill/training and time constraints

Armstrong, Lavery. Diabetes Care 2001: 24:1019-1022Armstrong, Lavery. Diabetes Care 2001: 24:1019-1022

DebridementDebridementRemoval of devitalized, nonviable Removal of devitalized, nonviable

tissue to help the diabetic ulcer tissue to help the diabetic ulcer heal more rapidly heal more rapidly

SurgicalSurgicalSharp Sharp

Steed. J Am Coll Surg 1996; 183: 61–4. Steed. J Am Coll Surg 1996; 183: 61–4.

DressingsDressingsMinimize further traumaMinimize further traumaMinimized infection riskMinimized infection riskOptimize environmentOptimize environment9 Topical trials9 Topical trials

Collagen, Gels, Foam, ORC Collagen, Collagen, Gels, Foam, ORC Collagen, Cadexomer Iodine, Alginate, Sodium CMCCadexomer Iodine, Alginate, Sodium CMC

Dressing BenefitsDressing BenefitsAbsorptionAbsorptionHydrationHydrationMoisture RetentionMoisture RetentionConforms to Depth Conforms to Depth

and contoursand contoursThermal InsulationThermal Insulation

Bacterial BarriersBacterial Barriers

Active Bacterial Active Bacterial ControlControl

Odor ControlOdor ControlAdherenceAdherence

Infection Infection ManagementManagement

Clinical uninfected < 10Clinical uninfected < 1055 org/gmorg/gm

Non-limb-threatening -Non-limb-threatening -superficialsuperficial

Limb-treatening Limb-treatening -involving tendon, -involving tendon, bone, capsule plus ischemiabone, capsule plus ischemia

Osteomyelitis –infected boneOsteomyelitis –infected bone

InfectionInfectionIncreased bacterial countIncreased bacterial count

10105 5 organism/gm of sampleorganism/gm of sampleErythema (Rubor)Erythema (Rubor)Warmth (Calor) Fever/ChillsWarmth (Calor) Fever/ChillsEdema (Tumor)Edema (Tumor)Pain (Dolor)Pain (Dolor)Uncontrollable Blood GlucoseUncontrollable Blood GlucoseDrainage Drainage Odor Odor

Vascular ReconstructionVascular ReconstructionFavorable results Favorable results Improved healingImproved healingReduced painReduced painImproved function/mobilityImproved function/mobility

Hirsch AT, et al. /J Vasc Interv RadiolHirsch AT, et al. /J Vasc Interv Radiol.. 2006 Sep;17(9):1383- 2006 Sep;17(9):1383-9797

AmputationAmputation

After extensive discussionAfter extensive discussionTreatment optionsTreatment optionsLevel of choiceLevel of choiceContralateral limbContralateral limb

Multidisciplinary Multidisciplinary CareCare

Patient and familyPatient and familyPhysicians and surgeonsPhysicians and surgeonsNurse/EducatorsNurse/EducatorsTherapistsTherapistsSocial workerSocial workerOrthotists, prosthetists, pedorthitistsOrthotists, prosthetists, pedorthitistsOthersOthers

ModificationsModificationsPersonal carePersonal careActivity limitationsActivity limitations

Assistive devicesAssistive devicesGait Gait

IrritationsIrritationsWound Wound

Repetitive walking stress is Repetitive walking stress is

the most common mechanismthe most common mechanism

of injury and faulty healing of injury and faulty healing

in the neuropathic foot.in the neuropathic foot.

Brand 1982Brand 1982 - Brand, 1982

•Medicare costs for patients with foot ulcers were 3 times higher than for diabetes patients in general.

• Inpatient care accounted for 74% of diabetic ulcer-related Medicare costs.

• Any wound care intervention that reduces the need for hospitalization should reduce costs.

- Harrington, 2000

Cost Analysis of Ulcer Care

Ulcer ManagementUlcer Management

Wound Care Wound Care

Off-LoadingOff-Loading

RemodelingRemodeling

Protective FootwearProtective Footwear

““The treatment of neuropathic foot The treatment of neuropathic foot ulcerations is (a matter of) mechanics ulcerations is (a matter of) mechanics

not medicine”not medicine”

Dr. Paul W. Brand 1915-2003Dr. Paul W. Brand 1915-2003

Insanity Is Continually Doing the

Same Thing Expecting Different Results

Thank youCordell “Corky” Atkins

PT, DPT, CWS, CDE, CPedCordell.Atkins@imail.org

Intermountain Medical Center Salt Lake City, Utah