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Auburn VNA Presentation 2010

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  • Prevention 4 RCTs of pressure relieving interventions were identified. Interventions for the prevention of diabetic foot ulcers indicated that in-shoe orthotics are of benefit. The relative merits of different in-shoe orthotics are unclear; cushioning and pressure redistribution appear of equal benefit. Other pressure relieving interventions such as running shoes have not been adequately evaluated and removable casts (Scotchcast or Hope) or foam inlays do not appear to have been evaluated at all in randomised controlled studies. Treatment 1 RCT of total contact casting indicated that it was effective in the treatment of diabetic ulcers although the evidence was limited .
  • Topical negative pressure therapy for treating chronic wounds Topical negative pressure (TNP) therapy is the application of negative pressure across a wound to aid wound healing. The pressure is thought to aid the drainage of excess fluid, reduce infection rates and increase localised blood flow. TNP is also known as vacuum assisted closure (VAC) and sealed surface wound suction. Seven trials compared TNP with either moistened gauze dressings or other topical agents and found no difference in effects. One very small, poor quality trial (7 wounds) showed a reduction in wound volume and depth in favour of TNP. There is no valid or reliable evidence that topical negative pressure increases chronic wound healing.
  • There is evidence to suggest that hydrogel increases the healing rate of diabetic foot ulcers compared with gauze dressings or standard care and larval therapy resulted in significantly greater reduction in wound area than hydrogel. More research is needed to evaluate the effects of a range of widely used debridement methods and of debridement per se.
  • 12 Weeks Sheehan 2003 Diabetes Care
  • Bring Semmes Weinstein tester and vibration tester
  • Affects C Fibers and A delta (small ones first)
  • Bring in pressure stat
  • Before and after
  • Transcript

    • 1. Auburn VNA Diagnosis and Management of Simple Podiatric Problems Don Pelto, DPM Central Massachusetts Podiatry, PC Worcester, MA
    • 2. Plantar Fasciitis / Heel Spur
      • Inflammation and partial tearing of a ligament band
      • Spur may be present
      • Pain first thing in morning
    • 3. Plantar Fasciitis Treatment
      • New shoes
      • Ice
      • NSAIDs
      • Night Splint
      • Stretching vs Deep Tissue Massage
    • 4. Plantar Fasciitis Treatment
      • Steroid Injection
        • 25G Needle
        • 3cc Syringe
        • 1cc 1% Lidocaine
        • 1cc 0.5% Marcaine
        • 0.5cc Kenalog
        • 0.5cc Dexamethasone
    • 5. Flat Feet
      • Congenital or acquired
      • Pain may occur in the feet, ankles, knees or back
    • 6. Flat Feet Treatment
      • Non-Custom Orthotics
      • Supportive Shoes
      • Orthotics
    • 7. Morton’s Neuroma
      • Compressed Nerve
      • Most often 3 rd interspace
      • Burning / pain on the ball of the foot or toes
      • r/o stress fracture, metatarsalgia
    • 8. Morton’s Neuroma Treatment
      • Wide shoes
      • No high heel shoes
      • NSAIDs
      • Physical Therapy
      • Orthotics
      • Metatarsal Pad
      • Steroid Injection
      • Sclerosing Injection 4%
        • 48cc 0.5% Marcaine with epi
        • 2cc Dehydrated Alcohol
    • 9. Hallux Valgus
      • Painful bump secondary to increase IM angle
      • Poor biomechanics
      • Hurts in shoes
      • Usually bump pain vs joint pain
      • Wider shoes help
      • Orthotics slow or stop progression and pain
    • 10. Hallux Valgus Treatment
      • Radiographs
      • Wider shoes
      • Padding, Bunion Bra
      • Trimming Keratoma
      • Corticosteroid Injection
        • Bump vs Joint
      • Orthotics slow or stop progression and pain
    • 11. Tailor’s Bunion / Bunionette
      • Bony deformity which is located on the outside part of the foot.
      • The bump, bunionette or Tailor’s Bunion, can become very painful due to shoe irritation.
      Note prominent 5 th metatarsal head
    • 12. Tailor’s Bunion / Bunionette
      • Wider shoes
      • Padding
      • Trimming Keratoma
      • Corticosteroid Injection
        • Bump vs Joint
      • Orthotics
    • 13. Hallux Rigidus
      • Arthritis of 1 st MPJ
      • Poor biomechanics
      • Painful to walk
    • 14. Hallux Rigidus Treatment
      • Cortisone injection
      • Physical therapy
      • NSAIDS
      • Orthotics
    • 15. Hammertoe Deformity
      • Digital contracture can be flexible or rigid in nature
      • Usually PIPJ
      • May have MPJ dorsiflexion
      • May have callus
      • Pre-ulcerative in patients with diabetes
    • 16. Hammertoe Treatment
      • Debridement
      • Padding
      • Shoe gear change
    • 17. Callous / Corn
      • Thickened skin caused by chronic rubbing or irritation of a bony prominence by the ground or shoe gear
    • 18. Callous / Corn Treatment
      • Trimming Callus
      • Callus Cream & Pumice Bar
      • Padding
      • Decreasing friction
      • Don't use acid pads
    • 19. Athlete's Foot
      • Fungal infection (Dermatophyte).
      • May occur anywhere on the foot and may burn and/or itch
      • The affected areas of skin will often peel or may have small blisters
    • 20. Athlete's Foot Treatment
      • Topical Antifungal – Cream vs Gel
      • Topical Steroid
      • May be dermatitis
      • Biopsy if not responding
    • 21. Plantar Wart
      • Human Papilloma Virus (HPV)
      • Contagious
      • Usually plantar on foot
    • 22. Verruca Treatment
      • Debridement
      • Chemocautery
      • Laser
      • Topical treatments
      • Oral Cimetidine for pediatric usage (30-40Mg/Kg in 3 divided doses)
      • Liquid Nitrogen not very effective on thick plantar foot skin
    • 23. Hyperhydrosis
      • Excess perspiration
      • Stress or overactive sweat glands
      • Predispose patient to fungal infections, bacterial infections or foot odor
      • Can be treated with topical medications
    • 24. Hyperhydrosis Treatment
      • Topical Formalin
      • Antiperspirant
      • Aluminum Hydroxychloride
      • Talc Power
      • Dry Wick Socks
    • 25. Ganglion Cyst
      • Benign soft tissue mass which arises from a weak area in a tendon lining or joint
      • Cyst is often filled with a gelatinous fluid
      • Cyst may change size depending on irritation
    • 26. Ganglion Cyst Treatment
      • Aspiration
      • Cortisone Injection
      • Trauma
      • Pressure
    • 27. Eczema/Fissures
      • Skin inflammatory condition
      • Worse in winter
      • Make sure not ulceration
    • 28. Ezema/Fissure Treatment
      • Cream
      • Pumice Stone
      • Off-loading Boot
    • 29. Eczema/Fissure Treatment
    • 30. Ingrown Nails/Paronychia
      • Painful to edge of nail with pressure or tight shoes
      • Erythema, edema, purulent exudate
    • 31. Ingrown Nail Treatment
      • Antibiotic
      • Massaging Nail Edge
      • I&D
      • Phenol & Alcohol (P&A)
    • 32. Onychomycosis
      • Dermatophyte
      • Often seen with skin manifestations
      • Usually acquired but may be inherited
      • May be caused by trauma
    • 33. Onychomycosis Treatment
      • Debridement
      • Topical Antifungal
      • Oral Antifungal
      • Nail Avulsion
      • Matrixectomy
      • Nail Biopsy
    • 34. Nail Injury
      • Chronic injury (i.e. athletic activities)
      • Isolated injury (trauma)
      • Nail bed laceration
    • 35. Nail Injury Treatment
      • Watch and wait
      • Nail avulsion
      • Puncture
    • 36. Subungual Exostosis
      • Bone and cartilage growth under the great toe nail
      • Pain may arise if pressure is placed over the area
    • 37. Subungual Exostosis Treatment
      • Shoe Modification
      • Toe Cap
      • Nail Avulsion
      • Cortisone Injection
      • Exostectomy
    • 38. Haglund’s Deformity / Retrocalcaneal Exostosis
      • Prominent bone on the back of the heel.
      • Back of the heel is irritated by shoes and activity.
    • 39. Haglund’s Deformity / Retrocalcaneal Exostosis Treatment
      • Open Backed Shoes
      • Steroid Injection around Bursa
      • Orthotics
    • 40. Fractures
      • 5 th Metatarsal – Difficulty healing
      • Digital
      • Calcaneus
      • Stress Fracture
    • 41. Fracture Treatment
      • Surgical Shoe
      • CAM Walker
      • Bone Stimulator
      • Buddy Taping
      • MRI vs CT
    • 42. Ulcerations
      • High pressure areas
      • Bony prominence
      • 4 Reasons Why Won’t Heal
        • High Glucose
        • Poor Circulation
        • Deeper Infection
        • Walking on Wound
    • 43. Diabetic Ulcer Treatment
      • X-rays: Rule out osteomylits
      • Debride the wound to granular bed
      • Remove hyperkeratosis
      • Gently probe wound for deep sinus
      • Apply DSD
      • Consider other wound products
      • Consider offloading
    • 44. Dermatological Considerations
      • Dry Skin
      • Fungal Infection
      • Callus
      • Interdigital lesions
      • Ingrown Nail
      • Ulceration
    • 45. Dermatological Considerations
      • Dry Skin
      • Fungal Infection
      • Callus
      • Interdigital lesions
      • Ingrown Nail
      • Ulceration
    • 46. Dermatological Considerations
      • Dry Skin
      • Fungal Infection
      • Callus
      • Interdigital lesions
      • Ingrown Nail
      • Ulceration
      Spencer SA. Pressure relieving interventions for preventing and treating diabetic foot ulcers. Cochrane Database of Systematic Reviews 2000, Issue 3. Art. No.: CD002302. DOI: 10.1002/14651858.CD002302.
    • 47. Dermatological Treatments
      • Callus
        • Diabetic shoes
      • Ulceration
        • VAC
        • Debridement
        • Dermal Skin Substitute
        • Platelet Rich Plasma
      Spencer SA. Pressure relieving interventions for preventing and treating diabetic foot ulcers. Cochrane Database of Systematic Reviews 2000, Issue 3. Art. No.: CD002302. DOI: 10.1002/14651858.CD002302.
    • 48. Dermatological Treatments
      • Callus
        • Diabetic shoes
      • Ulceration
        • VAC
        • Debridement
        • Dermal Skin Substitute
        • Platelet Rich Plasma
      Ubbink DT, Westerbos SJ, Evans D, Land L, Vermeulen H. Topical negative pressure for treating chronic wounds. Cochrane Database of Systematic Reviews 2008, Issue 3. Art. No.: CD001898. DOI: 10.1002/14651858.CD001898.pub2.
    • 49. Dermatological Treatments
      • Callus
        • Diabetic shoes
      • Ulceration
        • VAC
        • Debridement
        • Dermal Skin Substitute
        • Platelet Rich Plasma
      Edwards J, Stapley S. Debridement of diabetic foot ulcers. Cochrane Database of Systematic Reviews 2010, Issue 1.
    • 50. Dermatological Treatments
      • Callus
        • Diabetic shoes
      • Ulceration
        • VAC
        • Debridement
        • Dermal Skin Substitute
        • Platelet Rich Plasma
    • 51. Dermatological Treatments
      • Callus
        • Diabetic shoes
      • Ulceration
        • VAC
        • Debridement
        • Dermal Skin Substitute
        • Platelet Rich Plasma
    • 52. Dermatological Treatments
      • Callus
        • Diabetic shoes
      • Ulceration
        • VAC
        • Debridement
        • Dermal Skin Substitute
        • Platelet Rich Plasma
    • 53. Nerve Considerations
      • Neuropathy
      • Semmes Weinstein 5.07 monofilament (10g)
      • EMG and NCV
    • 54. Nerve Treatments
      • Neuropathy
        • Medication Oral
        • Topical Medication
        • ENFB (Epidermal Nerve Fiber Biopsy)
    • 55. Musculoskeletal Considerations
      • Foot Deformities
      • Plantar Pressure
      • Charcot Joint
    • 56. Musculoskeletal Considerations
      • Foot Deformities
      • Plantar Pressure
      • Charcot Joint
    • 57. Musculoskeletal Considerations
      • Foot Deformities
      • Gait Evaluation
      • Plantar Pressure
      • Charcot Joint
    • 58. Musculoskeletal Treatments
      • Foot Deformities
        • Preventative foot surgery
    • 59. Therapeutic Shoes
      • Focal pressure keratosis with accompanying risk factors are the major cause of ulcer.
      • Patients who have regular, frequent foot clinic visits that include risk evaluation, debridement of lesions, prescription of appropriate shoes and patient education are less likely to ulcerate. 1
      • 1 Sage RA, Webster JK, Fisher SG: Outpatient Care and Morbidity Reduction in Diabetic Foot Ulcers Associated with Chronic Pressure Callus. JAPMA 91 :275, 2001.
    • 60. Therapeutic Shoes
      • Need to have Diabetes and
        • Partial/Complete Amputation
        • Previous Ulceration
        • Pre-Ulcerative Callus
        • Neuropathy with Callus
        • Foot Deformity
        • Poor Circulation
    • 61. Thank You Don Pelto, DPM Central Massachusetts Podiatry, PC Worcester, MA [email_address] (508) 757-4003

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