wound

1. Pedal Wounds
and
Treatment Principles
Michael Gruse Jr. DPM/PGY-1

2. Wound Healing
Wound repair requires an
environment which is conducive to
epithelialization, collagen
formation, angiogenesis, and
wound contracture
Cleveland VA Medical Center

3. Treatment Principles
Establish
Etiology or Pathology
of
Ulcer
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4. Treatment Principles
Arterial Ulcers
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No flow - No go
Must Establish Flow

8. Treatment Principles
Arterial Ulcers
Establish flow
• Anti Platelet Medication
• Pletal (cilostazol)
• Plavix (clopidogrel)
• Referral to Vascular Surgeon
Cleveland VA Medical Center

9. Next Step?

10. Treatment Principles
Prevention
Do not allow Chronic Venous
Insufficiency to progress to ulceration
Venous Ulcers
Cleveland VA Medical Center

11. Venous Insufficiency

13. Treatment Principles
Prevent edema
• Elevation
• Compression
• Support Hose
• Intermittent Compression Pump
Venous Ulcers
Cleveland VA Medical Center

15. Treatment Principles
Skin Care
• Maintain moisture
• Treat stasis dermatitis
Venous Ulcers
Cleveland VA Medical Center

16. Treatment Principles
Venous Ulcers
Cleveland VA Medical Center
Trauma

17. Treatment Principles
Prevention
Neuropathic Ulcers
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20. Treatment Principles
Prevention
• Good glycemic control
• Daily foot inspections
• "Diabetic" socks
• Change shoes in middle of day
• Weight distributing insoles q6months
• Regular professional care
Neuropathic Ulcers
Cleveland VA Medical Center

21. Treatment Principles
REMOVE EXCESSIVE PRESSURE
or
DISTRIBUTE PRESSURE EVENLY
Neuropathic Ulcers
Cleveland VA Medical Center

22. Treatment Principles
Methods of Reducing Pressure
•Total Contact Cast
•Felted foam dressings
•Firm but moldable insoles
•Rocker bottom soles
•Metatarsal bars
•Non-weight bearing
Neuropathic Ulcers
Cleveland VA Medical Center

23. Treatment Principles
After etiology is addressed
Provide Normal Wound Care
Must Understand Eiology of Wound
Cleveland VA Medical Center

24. Treatment Principles
Diagnose and Control Infection
• signs and symptoms
• radiographs
• wound cultures and sensitivities
• antibiosis
Treatment of Dermal Wounds
Cleveland VA Medical Center

25. Is it infected?

26. Treatment Principles
Diagnose and Control Infection
Signs and Symptoms
• Fever
• Cellulitis - Lymphangitis
• Drainage
• Foul odor
• Palpable - tender lymph nodes
Treatment of Dermal Wounds
Cleveland VA Medical Center

27. Treatment Principles
Diagnose and Control Infection
Radiographs
• baseline
• soft tissue swelling & density
• soft tissue planes
• gas
• bone involvement
Treatment of Dermal Wounds
Cleveland VA Medical Center

28. Treatment Principles
Diagnose and Control Infection
Wound cultures and Sensitivities
• Curette base of wound
• aerobic and anaerobic if indicated
• If wound probes to bone – it is infected until proven otherwise
Treatment of Dermal Wounds
Cleveland VA Medical Center

29. Treatment Principles
Diagnose and Control Infection
Antibiosis
• begin broad spectrum coverage
• Cover MRSA if recent antibiotics or hx of MRSA
• reassess after culture is returned
Treatment of Dermal Wounds
Cleveland VA Medical Center

30. Treatment Principles
Debridement
should be
aggressive and thorough
Treatment of Dermal Wounds
Cleveland VA Medical Center

31. Treatment Principles
Debridement
• sharp debridement if applicable
• wet to dry dressings
• saline preferred
• Dakin's-Betadine-Peroxide-Acetic acid ?
• enzymatic debridement if ischemic
• autolysis
Treatment of Dermal Wounds
Cleveland VA Medical Center

32. Treatment Principles
AUTOLYSIS
the body's wound fluid hydrates and lyses
the wound by mobilizing the body's own
enzymes
Treatment of Dermal Wounds
Cleveland VA Medical Center

33. Treatment Principles
Wound Dressings
A moist wound environment is
physiologic and speeds
epithelialization
Treatment of Dermal Wounds
Cleveland VA Medical Center

34. Treatment Principles
Wound Dressings
• Epithelialization occurs up to
50% faster in a moist
environment than in a dry
environment.
• Wound fluid possesses growth factors
that stimulate angiogenesis and
epithelialization
Treatment of Dermal Wounds
Cleveland VA Medical Center

35. Treatment Principles
Wound Dressings
There is no evidence that anything
stimulates granulation tissue with
the possible exception of growth
factors
Treatment of Dermal Wounds
Cleveland VA Medical Center

36. Treatment Principles
Phases of Healing
Cleveland VA Medical Center
I. Inflammatory Phase
Erythema, warmth, edema, pain
A) Vasoconstriction
B) Vasodilation
C) Leukocyte migration
D) Monocytes > macrophages

37. Treatment Principles
Phases of Healing
Cleveland VA Medical Center
II. Proliferative Phase
• Beefy red granulation tissue
Macrophages
Collagen synthesis
Angiogenesis
• Thin, silvery epithelial layer
Epithelialization
• Wound shrinkage
Contraction

38. Treatment Principles
Phases of Healing
Cleveland VA Medical Center
III. Maturation Phase
Shrinkage, thinning, paling of scar
Collagen remodeling
Capillary regression
Tensile strength increases

39. Treatment Principles
Ask yourself the following questions
Is it arterial?
Is it venous?
Is it neuropathic?
Is it infected?
Is there osteomyelitis?
SUMMARY
Cleveland VA Medical Center

40. ?