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3 ER CURSO LATINO AMERICANO DE
CICATRIZACIÓN AVANZADA EN HERIDAS
WOUND DIAGNOSIS AND
TREATMENT BY ETIOLOGY
ARTERIAL, VENOUS, NEUROPATHIC/DIABETIC


           Tammy Luttrell MSPT, PhD, CWS , FACCWS

                     Profesora Adjunto
         Colorado Univerisity, Anschutz Medical Campus
                    National Jewish Health
WOUND HEALING PHASES

• Acute wounds heal by predictable and timely
  course of events
 • Hemostasis
 • Inflammation
 • Proliferation
   • Granulation
   • Epithelialization
 • Remodeling
CHRONIC WOUNDS

“those wounds that fail to progress through a normal,
  orderly, and timely sequence of repair or wounds
  that pass through the repair process without
  restoring anatomic and functional results”
 Lazarus, GS, et al. (1994) Definitions and guidelines for assessment for
 wounds and evaluation of healing. Arch of Derm. 130, 489-493.
CHRONIC WOUNDS

• Characteristics
  •   Necrotic tissue
  •   Bioburden
  •   Chronic inflammation
  •   Impaired hemodynamics
  •   Senescent fibroblasts and keratinocytes
  •   Chronic wound fluid with growth inhibiting proteases
  •   Overgrowth of epithelium with lack of underlying
      connective tissue => rolled edges
DIAGNOSING WOUNDS

• By tissue involvement (to determine local
  care)
  • Superficial
  • Partial thickness
  • Full thickness
• By etiology (to determine systemic care)
  • Arterial
  • Venous insufficiency
  • Neuropathic
  • Pressure
  • Atypical
CHRONIC WOUNDS:
      90% BELONG TO ONE OF 4 CATEGORIES
•   Ischemia
•   Micro or Macro Vascular Disease
•   Smoking
                                                   Arterial

                                                           •   Deep Vein Thrombosis (37%)
                                                           •   Recent Surgery, Ankle fusion
                       Venous Insufficiency                •   Prolonged standing, Pregnancy
                                                           •   Congestive heart failure


•   Diabetes
•   Peripheral Vascular Disease              Neuropathic/Diabetic
•   Hansen’s Disease

                                                           •   Pressure or Shear
                                                           •   Immobility, Moisture
                                  Pressure                 •   Decreased Sensation
                                                           •   Poor Nutrition

9/19/2012                             Comprehensive Exam
ARTERIAL WOUNDS

• Caused by ischemia
• Usually located at the peripheral extremities
• Caused by macro- or microvascular disease
 • Macro – obstruction of the larger named arteries by
   PVD, embolus, thrombus, trauma
 • Micro – disease of the small unnamed arterioles and
   capillaries, usually with diabetes or small emboli after
   some type of vascular surgery
PERIPHERAL VASCULAR DISEASE

• Arteriosclerosis
  • abnormal thickening and hardening of the artery walls
  • Smooth muscle cells and collagen fibers migrate into
    the inner arterial wall and cause it to harden
• Atherosclerosis
  • Arteriosclerosis in which fat and fibrin deposit on the
    inner walls of the arteries
  • Begins with a fatty streak and then becomes a fibrous
    plaque
ARTERIOSCLEROSIS
THICKENING OF THE ARTERIAL WALLS
ATHEROSCLEROSIS
CHOLESTEROL/FAT DEPOSITS – SITE OF MICROINFLAMMATION
PVD – CRITICAL PHASES

1. Collateral circulation insufficient for metabolic needs =>
  shunting of blood to muscles where there is less resistance
  => delayed healing of traumatic wounds
2. Claudication - pain with activity – most effectively
  treated with exercise
       a. thigh and buttock claudication = aortoiliac or
       iliac involvement
       b. calf claudication = femoral or popliteal
  involvement
3. Rest pain – requires revascularization surgery
   • May have “dependent leg syndrome”
   • May be accompanied by signs of ischemia at distal digits
MICROVASCULAR DISEASE

• Occlusion of the small arteries too small to be
  named (<0.5mm)
• Most frequently seen in patients with diabetes
• Cannot be treated with vascular surgery
• May result in non-healing wounds even after
  revascularization
ARTERIAL WOUNDS
• Evaluation
  •   Pulses
  •   Capillary refill time
  •   Rubor of dependency
  •   Skin appearance – shiny, thin, pale, NO hair growth
  •   Condition of nails and hair
  •   Location – distal toes or fingers
  •   Edges – even, punched out appearance
  •   Tissue – dry, necrotic, little or no granulation
ARTERIAL SCREENING

• Pulses                   • Grading
  • Upper extremity         •   0 = no pulse
    • Brachial              •   1+ = barely felt
    • Radial                •   2+ = diminished
    • Ulnar                 •   3+ = normal
                            •   4+ = bounding
  • Lower extremity             (indicative of
    • Femoral                   aneurysm)
    • Popliteal
    • Dorsalis pedis        Doppler signal is NOT
    • Posterior tibialis     equal to a palpable
                             pulse!!!
ARTERIAL SCREENING

• Rubor of dependency
 • Elevate the lower extremity 45 , note slight blanching of
   plant surface
 • Place in dependent position, redness or rubor that takes 30
   secs or more to occur
 • Indicative of arterial disease, usually advanced
ARTERIAL SCREENING

• Capillary refill

  • Detects microvascular disease
  • Press the end of any toe for 2-3 seconds and observe for
    blanching
  • Normal refill is less than 3 seconds
PAD
PUNCTATE WOUNDS
SMALL TOE NECROSIS DUE TO PAD
BUERGER DISEASE

• Also known as thromboangiitis obliterans
• Disease of macrovascular circulation
• Occurs in feet and/or hands
• More common in men, especially heavy
  smokers
• Pathology
    • Inflammation of the peripheral arteries with thrombi
      and vasospasm
BUERGER DISEASE

• Symptoms
  • Pain and tenderness
  • Redness
  • Cyanotic skin
  • Thin shiny skin
  • Thick malformed nails
  • Gangrene or ulcers (advanced cases)

 Age may assist in diagnosis – usually younger than
  typical patient with arterial wounds.

 Arterial wounds in younger patients indicative of
  some other pathology.
INVASIVE TESTS FOR PVD

• Arteriogram
 • Radiographs of
   vascular system after
   injection of
   radiopaque dye
 • Used to determine
   specific site of lesion
   prior to by-pass
   surgery
NON-INVASIVE TESTS FOR
      MACROVASCULAR DISEASE
• Ankle-brachial index
• Doppler arterial waveforms
• Ultrasound duplex scanning
  • Ultrasound
  • Doppler
• Color flow doppler scanning
• Great toe pressure
• Plethysmography (measures volume)
• Segmental blood pressure recordings
• Exercise stress test
ABI ---ANKLE BRACHIAL INDEX
 (ABPI-ANKLE BRACHIAL PRESSURE INDEX)




• Where PLeg is the systolic blood pressure of dorsalis
  pedis or posterior tibial arteries and
• PArm is the highest of the left and right arm brachial
  systolic blood pressure
ANKLE-BRACHIAL INDEX

• Ratio of ankle systolic pressure to brachial systolic pressure
• Indicates the severity of PVD
• Interpretations
   • 1.0– 1.2 – normal
   • 0.8-1.0 – minimal peripheral arterial disease.
     Compression for edema control is safe to use.
   • 0.5-0.8 – moderate peripheral arterial disease, often
     accompanied by intermittent claudication. Referral to
     a vascular specialist is advised. Compression therapy is
     contraindicated if <0.6; modified compression is
     indicated if 0.6-0.8.
   • <0.5 – severe ischemia with resting pain. Compression
     therapy is always contraindicated.
   • <0.2 – tissue death will occur.
Presión máxima tobillo
                            Indice
  Presión en el          tobillo-brazo =     derechoPresión máxima
  brazo derecho            derecho                  brazo (mm Hg)
  e izquierdo


           Presión máxima
               tobillo              92 mm Hg                Obstrucción
                                =               =   0.56=    moderada
           Presión braquial         164 mm Hg
               máxima

Presión en la arteria                   Interpretación del índice
tibial  posterior    y                         calculado

pedia    del   tobillo                  Por encima de 0.90 – normal

derecho e izquierdo                     0.71 – 0.90 – obstrucción leve

                                        0.41 – 0.70 – obstrucción moderada

                                        0.00 – 0.40 – obstrucción severa




       N Engl J Med 355; august 3, 2006
ANKLE-BRACHIAL INDEX

• ABI > 1.3 is not reliable
  • Frequently seen in diabetics
  • Caused by calcification of the arteries resulting in
    artificially high systolic pressure
  • Great toe pressure and toe/brachial index used
    instead of ABI
     • Normal > 55 mmHg pressure
     • Normal TBI – 0.8-0.99
     • < 30 mmHg – pt will need revascularization
Indice Tobillo-Brazo
PREVENTION OF ARTERIAL WOUNDS

• No smoking
• Control blood sugars
• Control hypertension, hyperlipidemia,
  hypercholesterolemia
• Provide proper foot care (Goodman, p454)
• Exercise (Goodman, p 455)
Cuidado Pre-Operatorio
 No haga desbridamiento.
 Mantenga el área seca; proteja los dedos con
  algodón o gaza estéril entre ellos.
 Use una cuna para los piés
 Descargue los talones con
  almohadas
 Eschar management – Dry and intact, paint with
  Betadine, use of dry topical silver. Eschar is the
  “barrier” substitute.
 Do not debride
 Keep area dry; protect toes with
  cotton or sterile gauze between toes
 Use foot cradle
 Off-load heels with pillows
Cuidado Pre-Operatorio
 No haga desbridamiento.
 Mantenga el área seca; proteja los dedos con
  algodón o gaza estéril entre ellos.
 Use una cuna para los piés
 Descargue los talones con
  almohadas



 Disminuya elevación de la extremidad
 Eleve la cabecera de la cama 5-7 grados
 Mantenga la extremidad caliente
 Evite ejercicio en exceso
TRATAMIENTO DESPUÉS DE CIRUGÍA

 Desbride la herida con tejido necrótico
  cuando haya tejido de granulación visible en
  sus bordes. (D. Armstrong)
 Provea un medio ambiente húmedo con el
  apósito avanzado apropiado.
 Proteja los piés con almohadas debajo de las
  pantorrillas.

• Debride wound of necrotic tissue when granulation tissue is visible
  at the edges (D. Armstrong)
• Provide moist wound environment with the appropriate advanced
  dressing
• Protect foot with pillows under calves
Apósitos
Protector




Posicionador
TRATAMIENTO DESPUÉS DE CIRUGÍA
 Descargue la herida con ortóticos, zapatos
  especiales, dispositivos.
 Controle el edema post-operatorio para
  prevenir dehiscencia de sutura.
    Cubra la incisión con gaza estéril seca
    Aplique vendaje de corta elasticidad en forma de
     espiral


• Off-load wound with orthotic, special shoes, assistive device
• Control post-op edema to prevent incisional dehiscence
  • Cover incision with dry sterile gauze
  • Apply short stretch elastic bandage in spiral wrap
GIVE AND TAKE OF ARTERIAL
           WOUNDS


• GIVE
  • Blood supply
  • Protection
• TAKE
  • Any cause of trauma
  • Necrotic tissue if signs of infection are
    present
VENOUS WOUNDS
•   Relate to ≈70% of LE wounds
•   500,000-1,000,000 in US
•   40% occur before the age of 50
•   Recurrence rate is as high as 72%
•   Estimated cost of care $40,000/case
VENOUS SYSTEM

• Superficial veins
  • Great saphenous
  • Small saphenous
• Deep veins
  • Femoral
  • popliteal
• Perforator veins
• Lymphatic system
CHRONIC VENOUS INSUFFICIENCY

• Causes
  • Reflux as a result of incompetent valves in the perforator,
    superficial, or deep veins
  • Obstruction – e.g. chronic deep vein thrombosis
  • Lack of venous pump activation during the gait cycle
    • Dorsiflexion – calf muscles compress deep veins with up to 250
      mmHg pressure
    • Plantarflexion – deep vein pressure falls and allows blood to flow
      from superficial veins to deep veins, through perforators
    • Does not occur with ankle hypomobility or gastrocsoleus
      weakness/paralysis
• Results in venous hypertension and excessive moisture in
  the interstitial tissue
• Prevents adequate oxygen and nutrients from reaching the
  skin
VENOUS PUMP




James, R et.al.: Incompetent venous valves: ultrasound imaging and exo-
stent repair
Phlebolymphology N°56
PATHOPHYSIOLOGICAL CHANGES

• Vessel dilatation and elongation
• Increased collagen deposition in both vein walls
  and skin
• Plasma protein leaks into interstitial space with
  resulting fibrin cuff around arterioles
• Increased leukocytes with decreased immune
  function
• Increased inflammatory cells resulting in tissue
  remodeling and dermal fibrosis
RISK FACTORS

•   Hx of DVT (37%)
•   Hx of hip/knee/calf surgery
•   Ankle hypomobility/fusion
•   Employment involving prolonged standing
•   Morbid obesity
•   Pregnancy
•   Congestive heart failure
Systemic disorders will cause bilateral
 edema; extremity dysfunctions will
 cause unilateral edema.
PROGRESSION OF VENOUS DISEASE

• Heavy, aching
  feeling in legs
• Telegentsia or
  reticular veins
• Varicose veins
• Edema without
  ulceration
• Skin changes
  without ulceration
• Skin changes with
  ulceration
COMMON SKIN CHANGES – CRITICAL IN
             DIAGNOSING CVI
•   Hyperpigmentation (hemosiderin)
•   Lipodermatosclerosis
•   Dilated long saphenous vein
•   Atrophie blanche
•   Unlateral or bilateral edema
•   Dermatitis
•   Thickened skin
•   Cellulitis
WHERE ARE ALL THE
WOUNDS LOCATED???
WHERE ARE VENOUS WOUNDS
             LOCATED?

In the gaiter area
VENOUS WOUND EVALUATION


• Girth of arch, malleoulus, calf
• Type and amount of drainage
• Edges (uneven) and location (gaiter,
  above the ankle)
• Pulse exam/ABI in case of absent pulses,
  severe pain, failure to heal with
  standard care
• Other components of any wound
  evaluation
VASCULAR TESTS - SCREENING

• Approximation of central venous pressure
 • Screens for cardiac incompetence as cause of
   edema
• Jugular distention
 • Indicates right ventricular failure
• Valve competency with Doppler
• Percussion test for saphenous vein
  competency
• Homan’s sign – not reliable
• Ankle-brachial index – r/o arterial component
VASCULAR TESTS/VALVE
          COMPETENCY

• Place probe over
  distended vein
• Compress vein 10-15 cm
  proximally
  • Audible sound (reflux)
    means valves between
    compression and probe
    are incompetent
• Compress vein distal to
  probe
  • NO audible sounds
    indicates venous
    obstruction
TREATMENT - PREVENTION
•   Compression hosiery
•   Elevation (higher than heart)
•   Exercise to activate venous pump
•   Avoid prolonged sitting or standing
•   Avoid crossing the legs
•   Skin lubrication
COMPRESSION HOSE

• Class I
   • 20-30 mmHg pressure
   • Used for venous disease with skin changes
• Class II
   • 30-40 mmHg pressure
   • Used for history of ulceration or severe skin changes
• Class III
   • 40-50 mmHg pressure
   • Used for lymphedema, pts who reulcerate with Class II, pts who work
     standing (e.g. dentists)
• Class IV
   • > 60 mmHg pressure

   TED hose used for DVT prophylaxis are NOT sufficient for
     treatment of Chronic Venous Ulcers I!!!
CIRCAID COMPRESSION GARMENT
COMPRESSION HOSE WITH ZIPPER
MAN’S COMPRESSION
       SOCK
VENOUS WOUND TREATMENT

• Cleanse and debride wound
• Apply appropriate primary dressing
• Compression therapy
 •   Support systems – Unna boot
 •   Multi-layer compression bandages – Profore
 •   Long-stretch bandages – Seto-press
 •   Short-stretch bandages – Comprilan
 •   Circ-Aid
 •   Intermittent compression therapy
LAPLACE EQUATION

• P = (TN x 4630) / CW
  • P = pressure in mmHg
  • T = bandage tension (in kgf)
  • N = number of layers applied
  • C = circumference of the limb (in cm)
  • W = bandage width(in cm)
  The pressure gradient between the ankle and calf makes the
    compression effective in managing the edema.
Compresión Modificada



Cast Padding                        Conforming Gauze




         Short Stretch   Bandages

           Modified Compression
INTERMITTENT COMPRESSION THERAPY

• Used as adjunct for wounds that do not
  respond to other compression methods or for
  maintenance in severe lymphedema
• Applies compression in sequence, distal to
  proximal
• Pressure must be less than the diastolic BP
  (usually ≈50 mmHg)
• Recommend 1-2 hours daily or bid, depending
  on severity
GIVE AND TAKE OF VENOUS
                 WOUNDS

• GIVE
 • Protection
 • Compression
 • Exercise
• TAKE
 • Edema
 • Bacteria
 • Devitalized tissue
DIABETIC / NEUROPATHIC WOUNDS
• Occur on the foot, usually plantar surface or toes
• Caused by mechanical forces or minor trauma
• Occur in patients with diabetes, PVD, or Hansen’s
  disease because of peripheral neuropathies
INCIDENCE IN DIABETICS

• 18.2 million people in US have DM (6.3% of the total
  population)
• In certain ethnic groups, % is as high as 14.5%
• 15% of people with DM will have neuropathic ulcer
• 14-24% of those with ulcer will have amputation
NEUROPATHIES
• Motor – muscle weakness => changes in the
  shape of the foot => high peak pressures during
  weight bearing activities
 • Caused by damage to large nerve fibers
• Sensory – diminished sensation => lack of
  protective sensation
 • Caused by damage to small nerve fibers
• Autonomic – decreases sweat and oil
  production => dry, inelastic skin
 • Caused by damage to the large nerve fibers and the
   sympathetic ganglion
COMMON FOOT DEFORMITIES

•   Pes aquinas – short Achilles tendon
•   Hallux limitus/rigidus
•   Hallux valgus
•   Hammer toes
•   Cock-up deformity
•   Varus deformities of toes
•   Tailors bunion on 5th metatarsal head
•   Charcot foot – collapse of arch
NEUROPATHIC WOUND
      CLASSIFICATION

Wagner scale
•   0 – at risk due to skin and foot changes
•   1 – full thickness skin loss, no infection
•   2 – subcutaneous tissue loss, infection
•   3 – deep ulceration, infection, osteomyelitis or abscess
•   4 – partial foot gangrene or necrosis
•   5 – full foot gangrene
WAGNER GRADE 0
AT RISK DUE TO SKIN AND FOOT CHANGES
WAGNER GRADE 1
FULL THICKNESS SKIN LOSS
WAGNER GRADE 2
SUBCUTANEOUS TISSUE LOSS, INFECTION
WAGNER GRADE 3
D E E P U L C E R AT I O N , I N F E C T I O N , O S T E O M Y E L I T I S O R A B S C E S S
WAGNER GRADE 4
PA R T I A L F O O T G A N G R E N E O R N E C R O S I S
WAGNER GRADE 5
FULL FOOT GANGRENE
EVALUATION
• Risk factors
  • Recent trauma, diet, footwear, poor foot hygiene, medications,
    comobidities
• Subjective history
• Skin inspection
  •   Dry skin with fissures
  •   Calluses
  •   Discoloration in dermal layer (RBCs from deep injury)
  •   Lack of toe and dorsal hair
• Heel inspection
• Toe inspection
  • Nail condition
  • Interdigital spaces
• Foot deformities
• Shoe assessment
EVALUATION
• Sensory assessment
• Vibration test
• Pressure assessment with Semmes-Weinstein
  monofilaments
• Skin temperature - 3 discrepancy is significant
• Reflexes
• Musculoskeletal assessment, especially ROM
 • Dorsiflexion - 10
 • Hallux extension – 50-60
PREDICTORS OF COMPLICATIONS

• Semmes-weinstein monofilaments
  • 3.61 (0.4g) = normal
  • 5.07 (10g) = loss of protective sensation
  • 6.10 (100g) = total loss of sensation
• Vibration
  • 128 Hz tuning fork
  • Measures only yes/no response
  • Test end of great toe, medial malleolus, tibial
    tuberosity
• Reflexes
  • Diminished due to large motor nerve involvement
  • Predictable pattern (LE>UE, distal>prox,
    symmetrical pattern)
NON-INVASIVE VASCULAR ASSESSMENT

• Pulses
• Capillary refill time
• Ankle brachial index
 • May be unreliable in diabetic if >1.3
• Great toe pressure
 • Normal is 60-90% of the brachial pressure
 • Normal TBI is 0.8-0.99
• Exercise stress test
• Transcutaneous oxygen tension
• Color flow Doppler imaging
TREATMENT - PREVENTION
• Patient education
  • Blood glucose control
  • Properly fitting shoes
  • Nail and callus care
  • Skin care
  • Diabetic or molded shoes if foot
    deformities are severe
BLOOD GLUCOSE CONTROL

• Normoglycemia – fasting <110mg/dl
• Impaired fasting glucose – 110-126
• Diagnosis of diabetes - >126
• Wound healing requires <200
• HB1Ac – < 6.5 for diabetics
PROPER FOOT CARE
• Properly fitting shoes
• Daily foot inspection
  • Check for red spots, blisters, calluses
  • Use mirror or family member if necessary
• Proper foot care
  • Never walk barefoot
  • Avoid soaking and hot surfaces
  • Lubricate skin well
  • Do not use adhesives on skin
  • Wear thick white cotton socks
  • Cut nails straight across
TREATMENT OF WOUNDS
•   Treat infection (systemic vs topical)
•   Revascularize if needed
•   Control blood sugars
•   Debride wound
•   Provide moist wound environment
•   OFF-LOAD
    • Pressure redistribution
    • Special shoes, total contact casting, assistive devices
OFF LOADING
TOTAL CONTACT CAST APPLICATION
OFF LOADING
TOTAL CONTACT CAST WITH WALKING SOLE
Zapatos
Apósito Acomodativo
GIVE AND TAKE OF NEUROPATHIC WOUNDS

• GIVE
  •   Antibiotics
  •   Blood supply
  •   Moist wound dressing
  •   Protection
  •   Patient education
• TAKE
  •   Bacteria
  •   Necrotic tissue
  •   Calluses
  •   Pressure
  •   Friction
¿Preguntas?




• Comaeu Pass, Glacier National Park

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3er Curso Latino Americano de Cicatrización Avanzada en Heridas (II)

  • 1. 3 ER CURSO LATINO AMERICANO DE CICATRIZACIÓN AVANZADA EN HERIDAS
  • 2. WOUND DIAGNOSIS AND TREATMENT BY ETIOLOGY ARTERIAL, VENOUS, NEUROPATHIC/DIABETIC Tammy Luttrell MSPT, PhD, CWS , FACCWS Profesora Adjunto Colorado Univerisity, Anschutz Medical Campus National Jewish Health
  • 3. WOUND HEALING PHASES • Acute wounds heal by predictable and timely course of events • Hemostasis • Inflammation • Proliferation • Granulation • Epithelialization • Remodeling
  • 4. CHRONIC WOUNDS “those wounds that fail to progress through a normal, orderly, and timely sequence of repair or wounds that pass through the repair process without restoring anatomic and functional results” Lazarus, GS, et al. (1994) Definitions and guidelines for assessment for wounds and evaluation of healing. Arch of Derm. 130, 489-493.
  • 5. CHRONIC WOUNDS • Characteristics • Necrotic tissue • Bioburden • Chronic inflammation • Impaired hemodynamics • Senescent fibroblasts and keratinocytes • Chronic wound fluid with growth inhibiting proteases • Overgrowth of epithelium with lack of underlying connective tissue => rolled edges
  • 6. DIAGNOSING WOUNDS • By tissue involvement (to determine local care) • Superficial • Partial thickness • Full thickness • By etiology (to determine systemic care) • Arterial • Venous insufficiency • Neuropathic • Pressure • Atypical
  • 7. CHRONIC WOUNDS: 90% BELONG TO ONE OF 4 CATEGORIES • Ischemia • Micro or Macro Vascular Disease • Smoking Arterial • Deep Vein Thrombosis (37%) • Recent Surgery, Ankle fusion Venous Insufficiency • Prolonged standing, Pregnancy • Congestive heart failure • Diabetes • Peripheral Vascular Disease Neuropathic/Diabetic • Hansen’s Disease • Pressure or Shear • Immobility, Moisture Pressure • Decreased Sensation • Poor Nutrition 9/19/2012 Comprehensive Exam
  • 8. ARTERIAL WOUNDS • Caused by ischemia • Usually located at the peripheral extremities • Caused by macro- or microvascular disease • Macro – obstruction of the larger named arteries by PVD, embolus, thrombus, trauma • Micro – disease of the small unnamed arterioles and capillaries, usually with diabetes or small emboli after some type of vascular surgery
  • 9. PERIPHERAL VASCULAR DISEASE • Arteriosclerosis • abnormal thickening and hardening of the artery walls • Smooth muscle cells and collagen fibers migrate into the inner arterial wall and cause it to harden • Atherosclerosis • Arteriosclerosis in which fat and fibrin deposit on the inner walls of the arteries • Begins with a fatty streak and then becomes a fibrous plaque
  • 11. ATHEROSCLEROSIS CHOLESTEROL/FAT DEPOSITS – SITE OF MICROINFLAMMATION
  • 12. PVD – CRITICAL PHASES 1. Collateral circulation insufficient for metabolic needs => shunting of blood to muscles where there is less resistance => delayed healing of traumatic wounds 2. Claudication - pain with activity – most effectively treated with exercise a. thigh and buttock claudication = aortoiliac or iliac involvement b. calf claudication = femoral or popliteal involvement 3. Rest pain – requires revascularization surgery • May have “dependent leg syndrome” • May be accompanied by signs of ischemia at distal digits
  • 13. MICROVASCULAR DISEASE • Occlusion of the small arteries too small to be named (<0.5mm) • Most frequently seen in patients with diabetes • Cannot be treated with vascular surgery • May result in non-healing wounds even after revascularization
  • 14. ARTERIAL WOUNDS • Evaluation • Pulses • Capillary refill time • Rubor of dependency • Skin appearance – shiny, thin, pale, NO hair growth • Condition of nails and hair • Location – distal toes or fingers • Edges – even, punched out appearance • Tissue – dry, necrotic, little or no granulation
  • 15. ARTERIAL SCREENING • Pulses • Grading • Upper extremity • 0 = no pulse • Brachial • 1+ = barely felt • Radial • 2+ = diminished • Ulnar • 3+ = normal • 4+ = bounding • Lower extremity (indicative of • Femoral aneurysm) • Popliteal • Dorsalis pedis Doppler signal is NOT • Posterior tibialis equal to a palpable pulse!!!
  • 16. ARTERIAL SCREENING • Rubor of dependency • Elevate the lower extremity 45 , note slight blanching of plant surface • Place in dependent position, redness or rubor that takes 30 secs or more to occur • Indicative of arterial disease, usually advanced
  • 17. ARTERIAL SCREENING • Capillary refill • Detects microvascular disease • Press the end of any toe for 2-3 seconds and observe for blanching • Normal refill is less than 3 seconds
  • 18.
  • 20. SMALL TOE NECROSIS DUE TO PAD
  • 21. BUERGER DISEASE • Also known as thromboangiitis obliterans • Disease of macrovascular circulation • Occurs in feet and/or hands • More common in men, especially heavy smokers • Pathology • Inflammation of the peripheral arteries with thrombi and vasospasm
  • 22. BUERGER DISEASE • Symptoms • Pain and tenderness • Redness • Cyanotic skin • Thin shiny skin • Thick malformed nails • Gangrene or ulcers (advanced cases) Age may assist in diagnosis – usually younger than typical patient with arterial wounds. Arterial wounds in younger patients indicative of some other pathology.
  • 23.
  • 24. INVASIVE TESTS FOR PVD • Arteriogram • Radiographs of vascular system after injection of radiopaque dye • Used to determine specific site of lesion prior to by-pass surgery
  • 25. NON-INVASIVE TESTS FOR MACROVASCULAR DISEASE • Ankle-brachial index • Doppler arterial waveforms • Ultrasound duplex scanning • Ultrasound • Doppler • Color flow doppler scanning • Great toe pressure • Plethysmography (measures volume) • Segmental blood pressure recordings • Exercise stress test
  • 26. ABI ---ANKLE BRACHIAL INDEX (ABPI-ANKLE BRACHIAL PRESSURE INDEX) • Where PLeg is the systolic blood pressure of dorsalis pedis or posterior tibial arteries and • PArm is the highest of the left and right arm brachial systolic blood pressure
  • 27. ANKLE-BRACHIAL INDEX • Ratio of ankle systolic pressure to brachial systolic pressure • Indicates the severity of PVD • Interpretations • 1.0– 1.2 – normal • 0.8-1.0 – minimal peripheral arterial disease. Compression for edema control is safe to use. • 0.5-0.8 – moderate peripheral arterial disease, often accompanied by intermittent claudication. Referral to a vascular specialist is advised. Compression therapy is contraindicated if <0.6; modified compression is indicated if 0.6-0.8. • <0.5 – severe ischemia with resting pain. Compression therapy is always contraindicated. • <0.2 – tissue death will occur.
  • 28. Presión máxima tobillo Indice Presión en el tobillo-brazo = derechoPresión máxima brazo derecho derecho brazo (mm Hg) e izquierdo Presión máxima tobillo 92 mm Hg Obstrucción = = 0.56= moderada Presión braquial 164 mm Hg máxima Presión en la arteria Interpretación del índice tibial posterior y calculado pedia del tobillo Por encima de 0.90 – normal derecho e izquierdo 0.71 – 0.90 – obstrucción leve 0.41 – 0.70 – obstrucción moderada 0.00 – 0.40 – obstrucción severa N Engl J Med 355; august 3, 2006
  • 29. ANKLE-BRACHIAL INDEX • ABI > 1.3 is not reliable • Frequently seen in diabetics • Caused by calcification of the arteries resulting in artificially high systolic pressure • Great toe pressure and toe/brachial index used instead of ABI • Normal > 55 mmHg pressure • Normal TBI – 0.8-0.99 • < 30 mmHg – pt will need revascularization
  • 31. PREVENTION OF ARTERIAL WOUNDS • No smoking • Control blood sugars • Control hypertension, hyperlipidemia, hypercholesterolemia • Provide proper foot care (Goodman, p454) • Exercise (Goodman, p 455)
  • 32. Cuidado Pre-Operatorio  No haga desbridamiento.  Mantenga el área seca; proteja los dedos con algodón o gaza estéril entre ellos.  Use una cuna para los piés  Descargue los talones con almohadas  Eschar management – Dry and intact, paint with Betadine, use of dry topical silver. Eschar is the “barrier” substitute.  Do not debride  Keep area dry; protect toes with cotton or sterile gauze between toes  Use foot cradle  Off-load heels with pillows
  • 33. Cuidado Pre-Operatorio  No haga desbridamiento.  Mantenga el área seca; proteja los dedos con algodón o gaza estéril entre ellos.  Use una cuna para los piés  Descargue los talones con almohadas  Disminuya elevación de la extremidad  Eleve la cabecera de la cama 5-7 grados  Mantenga la extremidad caliente  Evite ejercicio en exceso
  • 34. TRATAMIENTO DESPUÉS DE CIRUGÍA  Desbride la herida con tejido necrótico cuando haya tejido de granulación visible en sus bordes. (D. Armstrong)  Provea un medio ambiente húmedo con el apósito avanzado apropiado.  Proteja los piés con almohadas debajo de las pantorrillas. • Debride wound of necrotic tissue when granulation tissue is visible at the edges (D. Armstrong) • Provide moist wound environment with the appropriate advanced dressing • Protect foot with pillows under calves
  • 36.
  • 38. TRATAMIENTO DESPUÉS DE CIRUGÍA  Descargue la herida con ortóticos, zapatos especiales, dispositivos.  Controle el edema post-operatorio para prevenir dehiscencia de sutura.  Cubra la incisión con gaza estéril seca  Aplique vendaje de corta elasticidad en forma de espiral • Off-load wound with orthotic, special shoes, assistive device • Control post-op edema to prevent incisional dehiscence • Cover incision with dry sterile gauze • Apply short stretch elastic bandage in spiral wrap
  • 39.
  • 40.
  • 41.
  • 42. GIVE AND TAKE OF ARTERIAL WOUNDS • GIVE • Blood supply • Protection • TAKE • Any cause of trauma • Necrotic tissue if signs of infection are present
  • 43. VENOUS WOUNDS • Relate to ≈70% of LE wounds • 500,000-1,000,000 in US • 40% occur before the age of 50 • Recurrence rate is as high as 72% • Estimated cost of care $40,000/case
  • 44. VENOUS SYSTEM • Superficial veins • Great saphenous • Small saphenous • Deep veins • Femoral • popliteal • Perforator veins • Lymphatic system
  • 45. CHRONIC VENOUS INSUFFICIENCY • Causes • Reflux as a result of incompetent valves in the perforator, superficial, or deep veins • Obstruction – e.g. chronic deep vein thrombosis • Lack of venous pump activation during the gait cycle • Dorsiflexion – calf muscles compress deep veins with up to 250 mmHg pressure • Plantarflexion – deep vein pressure falls and allows blood to flow from superficial veins to deep veins, through perforators • Does not occur with ankle hypomobility or gastrocsoleus weakness/paralysis • Results in venous hypertension and excessive moisture in the interstitial tissue • Prevents adequate oxygen and nutrients from reaching the skin
  • 46. VENOUS PUMP James, R et.al.: Incompetent venous valves: ultrasound imaging and exo- stent repair Phlebolymphology N°56
  • 47. PATHOPHYSIOLOGICAL CHANGES • Vessel dilatation and elongation • Increased collagen deposition in both vein walls and skin • Plasma protein leaks into interstitial space with resulting fibrin cuff around arterioles • Increased leukocytes with decreased immune function • Increased inflammatory cells resulting in tissue remodeling and dermal fibrosis
  • 48. RISK FACTORS • Hx of DVT (37%) • Hx of hip/knee/calf surgery • Ankle hypomobility/fusion • Employment involving prolonged standing • Morbid obesity • Pregnancy • Congestive heart failure Systemic disorders will cause bilateral edema; extremity dysfunctions will cause unilateral edema.
  • 49. PROGRESSION OF VENOUS DISEASE • Heavy, aching feeling in legs • Telegentsia or reticular veins • Varicose veins • Edema without ulceration • Skin changes without ulceration • Skin changes with ulceration
  • 50. COMMON SKIN CHANGES – CRITICAL IN DIAGNOSING CVI • Hyperpigmentation (hemosiderin) • Lipodermatosclerosis • Dilated long saphenous vein • Atrophie blanche • Unlateral or bilateral edema • Dermatitis • Thickened skin • Cellulitis
  • 51.
  • 52.
  • 53.
  • 54. WHERE ARE ALL THE WOUNDS LOCATED???
  • 55. WHERE ARE VENOUS WOUNDS LOCATED? In the gaiter area
  • 56. VENOUS WOUND EVALUATION • Girth of arch, malleoulus, calf • Type and amount of drainage • Edges (uneven) and location (gaiter, above the ankle) • Pulse exam/ABI in case of absent pulses, severe pain, failure to heal with standard care • Other components of any wound evaluation
  • 57.
  • 58.
  • 59. VASCULAR TESTS - SCREENING • Approximation of central venous pressure • Screens for cardiac incompetence as cause of edema • Jugular distention • Indicates right ventricular failure • Valve competency with Doppler • Percussion test for saphenous vein competency • Homan’s sign – not reliable • Ankle-brachial index – r/o arterial component
  • 60. VASCULAR TESTS/VALVE COMPETENCY • Place probe over distended vein • Compress vein 10-15 cm proximally • Audible sound (reflux) means valves between compression and probe are incompetent • Compress vein distal to probe • NO audible sounds indicates venous obstruction
  • 61. TREATMENT - PREVENTION • Compression hosiery • Elevation (higher than heart) • Exercise to activate venous pump • Avoid prolonged sitting or standing • Avoid crossing the legs • Skin lubrication
  • 62. COMPRESSION HOSE • Class I • 20-30 mmHg pressure • Used for venous disease with skin changes • Class II • 30-40 mmHg pressure • Used for history of ulceration or severe skin changes • Class III • 40-50 mmHg pressure • Used for lymphedema, pts who reulcerate with Class II, pts who work standing (e.g. dentists) • Class IV • > 60 mmHg pressure TED hose used for DVT prophylaxis are NOT sufficient for treatment of Chronic Venous Ulcers I!!!
  • 63.
  • 67. VENOUS WOUND TREATMENT • Cleanse and debride wound • Apply appropriate primary dressing • Compression therapy • Support systems – Unna boot • Multi-layer compression bandages – Profore • Long-stretch bandages – Seto-press • Short-stretch bandages – Comprilan • Circ-Aid • Intermittent compression therapy
  • 68. LAPLACE EQUATION • P = (TN x 4630) / CW • P = pressure in mmHg • T = bandage tension (in kgf) • N = number of layers applied • C = circumference of the limb (in cm) • W = bandage width(in cm) The pressure gradient between the ankle and calf makes the compression effective in managing the edema.
  • 69.
  • 70.
  • 71.
  • 72. Compresión Modificada Cast Padding Conforming Gauze Short Stretch Bandages Modified Compression
  • 73.
  • 74. INTERMITTENT COMPRESSION THERAPY • Used as adjunct for wounds that do not respond to other compression methods or for maintenance in severe lymphedema • Applies compression in sequence, distal to proximal • Pressure must be less than the diastolic BP (usually ≈50 mmHg) • Recommend 1-2 hours daily or bid, depending on severity
  • 75.
  • 76. GIVE AND TAKE OF VENOUS WOUNDS • GIVE • Protection • Compression • Exercise • TAKE • Edema • Bacteria • Devitalized tissue
  • 77. DIABETIC / NEUROPATHIC WOUNDS • Occur on the foot, usually plantar surface or toes • Caused by mechanical forces or minor trauma • Occur in patients with diabetes, PVD, or Hansen’s disease because of peripheral neuropathies
  • 78. INCIDENCE IN DIABETICS • 18.2 million people in US have DM (6.3% of the total population) • In certain ethnic groups, % is as high as 14.5% • 15% of people with DM will have neuropathic ulcer • 14-24% of those with ulcer will have amputation
  • 79. NEUROPATHIES • Motor – muscle weakness => changes in the shape of the foot => high peak pressures during weight bearing activities • Caused by damage to large nerve fibers • Sensory – diminished sensation => lack of protective sensation • Caused by damage to small nerve fibers • Autonomic – decreases sweat and oil production => dry, inelastic skin • Caused by damage to the large nerve fibers and the sympathetic ganglion
  • 80. COMMON FOOT DEFORMITIES • Pes aquinas – short Achilles tendon • Hallux limitus/rigidus • Hallux valgus • Hammer toes • Cock-up deformity • Varus deformities of toes • Tailors bunion on 5th metatarsal head • Charcot foot – collapse of arch
  • 81. NEUROPATHIC WOUND CLASSIFICATION Wagner scale • 0 – at risk due to skin and foot changes • 1 – full thickness skin loss, no infection • 2 – subcutaneous tissue loss, infection • 3 – deep ulceration, infection, osteomyelitis or abscess • 4 – partial foot gangrene or necrosis • 5 – full foot gangrene
  • 82. WAGNER GRADE 0 AT RISK DUE TO SKIN AND FOOT CHANGES
  • 83. WAGNER GRADE 1 FULL THICKNESS SKIN LOSS
  • 84. WAGNER GRADE 2 SUBCUTANEOUS TISSUE LOSS, INFECTION
  • 85. WAGNER GRADE 3 D E E P U L C E R AT I O N , I N F E C T I O N , O S T E O M Y E L I T I S O R A B S C E S S
  • 86. WAGNER GRADE 4 PA R T I A L F O O T G A N G R E N E O R N E C R O S I S
  • 87. WAGNER GRADE 5 FULL FOOT GANGRENE
  • 88. EVALUATION • Risk factors • Recent trauma, diet, footwear, poor foot hygiene, medications, comobidities • Subjective history • Skin inspection • Dry skin with fissures • Calluses • Discoloration in dermal layer (RBCs from deep injury) • Lack of toe and dorsal hair • Heel inspection • Toe inspection • Nail condition • Interdigital spaces • Foot deformities • Shoe assessment
  • 89.
  • 90. EVALUATION • Sensory assessment • Vibration test • Pressure assessment with Semmes-Weinstein monofilaments • Skin temperature - 3 discrepancy is significant • Reflexes • Musculoskeletal assessment, especially ROM • Dorsiflexion - 10 • Hallux extension – 50-60
  • 91. PREDICTORS OF COMPLICATIONS • Semmes-weinstein monofilaments • 3.61 (0.4g) = normal • 5.07 (10g) = loss of protective sensation • 6.10 (100g) = total loss of sensation • Vibration • 128 Hz tuning fork • Measures only yes/no response • Test end of great toe, medial malleolus, tibial tuberosity • Reflexes • Diminished due to large motor nerve involvement • Predictable pattern (LE>UE, distal>prox, symmetrical pattern)
  • 92. NON-INVASIVE VASCULAR ASSESSMENT • Pulses • Capillary refill time • Ankle brachial index • May be unreliable in diabetic if >1.3 • Great toe pressure • Normal is 60-90% of the brachial pressure • Normal TBI is 0.8-0.99 • Exercise stress test • Transcutaneous oxygen tension • Color flow Doppler imaging
  • 93. TREATMENT - PREVENTION • Patient education • Blood glucose control • Properly fitting shoes • Nail and callus care • Skin care • Diabetic or molded shoes if foot deformities are severe
  • 94. BLOOD GLUCOSE CONTROL • Normoglycemia – fasting <110mg/dl • Impaired fasting glucose – 110-126 • Diagnosis of diabetes - >126 • Wound healing requires <200 • HB1Ac – < 6.5 for diabetics
  • 95. PROPER FOOT CARE • Properly fitting shoes • Daily foot inspection • Check for red spots, blisters, calluses • Use mirror or family member if necessary • Proper foot care • Never walk barefoot • Avoid soaking and hot surfaces • Lubricate skin well • Do not use adhesives on skin • Wear thick white cotton socks • Cut nails straight across
  • 96. TREATMENT OF WOUNDS • Treat infection (systemic vs topical) • Revascularize if needed • Control blood sugars • Debride wound • Provide moist wound environment • OFF-LOAD • Pressure redistribution • Special shoes, total contact casting, assistive devices
  • 97.
  • 98. OFF LOADING TOTAL CONTACT CAST APPLICATION
  • 99. OFF LOADING TOTAL CONTACT CAST WITH WALKING SOLE
  • 102. GIVE AND TAKE OF NEUROPATHIC WOUNDS • GIVE • Antibiotics • Blood supply • Moist wound dressing • Protection • Patient education • TAKE • Bacteria • Necrotic tissue • Calluses • Pressure • Friction
  • 103. ¿Preguntas? • Comaeu Pass, Glacier National Park

Editor's Notes

  1. 4 categories are largely a division of convenience: Treatment algorithms, reimbursement, research/literature, and statistical data are organized accordingly.