“Case Histories To Ponder” · NZWC CONFERENCE 2019 “Case Histories To Ponder” Difficult...
Transcript of “Case Histories To Ponder” · NZWC CONFERENCE 2019 “Case Histories To Ponder” Difficult...
![Page 1: “Case Histories To Ponder” · NZWC CONFERENCE 2019 “Case Histories To Ponder” Difficult wounds in the diabetic foot Roger Grech Senior Podiatrist CMDHB](https://reader034.fdocuments.in/reader034/viewer/2022050400/5f7e22e9de3c6028f135304e/html5/thumbnails/1.jpg)
NZWC CONFERENCE 2019
“Case Histories To Ponder”Difficult wounds in the diabetic foot
Roger GrechSenior Podiatrist CMDHB
![Page 2: “Case Histories To Ponder” · NZWC CONFERENCE 2019 “Case Histories To Ponder” Difficult wounds in the diabetic foot Roger Grech Senior Podiatrist CMDHB](https://reader034.fdocuments.in/reader034/viewer/2022050400/5f7e22e9de3c6028f135304e/html5/thumbnails/2.jpg)
Case 1
▪ 79 year old male (HbA1c 63)
▪ Type 2 diabetes
▪ Hypothyroidism
▪ Obesity
![Page 3: “Case Histories To Ponder” · NZWC CONFERENCE 2019 “Case Histories To Ponder” Difficult wounds in the diabetic foot Roger Grech Senior Podiatrist CMDHB](https://reader034.fdocuments.in/reader034/viewer/2022050400/5f7e22e9de3c6028f135304e/html5/thumbnails/3.jpg)
Presentation + History
▪ Non healing left foot ulcers
▪ Duration - 5 months
▪ R # Femur 6 months ago
▪ Altered gait
-overloading L foot?
▪ Previous skin graft
- melanoma excision 7yrs prior
![Page 4: “Case Histories To Ponder” · NZWC CONFERENCE 2019 “Case Histories To Ponder” Difficult wounds in the diabetic foot Roger Grech Senior Podiatrist CMDHB](https://reader034.fdocuments.in/reader034/viewer/2022050400/5f7e22e9de3c6028f135304e/html5/thumbnails/4.jpg)
Assessment + Investigations
▪ PT pulses palpable
▪ Patchy sensory neuropathy
▪ Suspicious Lesion
▪ Firm, raised nodule
▪ 12 mm diameter
▪ Urgent biopsy
▪ SCC or Amelanotic MM?
![Page 5: “Case Histories To Ponder” · NZWC CONFERENCE 2019 “Case Histories To Ponder” Difficult wounds in the diabetic foot Roger Grech Senior Podiatrist CMDHB](https://reader034.fdocuments.in/reader034/viewer/2022050400/5f7e22e9de3c6028f135304e/html5/thumbnails/5.jpg)
Management
Malignant melanoma
▪ Wide excision
▪ Split skin graft
▪ CT Scan no metastasis
▪ Offloading Shoe/Orthotic
![Page 6: “Case Histories To Ponder” · NZWC CONFERENCE 2019 “Case Histories To Ponder” Difficult wounds in the diabetic foot Roger Grech Senior Podiatrist CMDHB](https://reader034.fdocuments.in/reader034/viewer/2022050400/5f7e22e9de3c6028f135304e/html5/thumbnails/6.jpg)
Case 2
▪ 70 year old female
▪ Type 2 diabetes (HbA1c 70)
▪ Fijian Indian, no English
▪ Hypertension
▪ Elevated BMI
![Page 7: “Case Histories To Ponder” · NZWC CONFERENCE 2019 “Case Histories To Ponder” Difficult wounds in the diabetic foot Roger Grech Senior Podiatrist CMDHB](https://reader034.fdocuments.in/reader034/viewer/2022050400/5f7e22e9de3c6028f135304e/html5/thumbnails/7.jpg)
Presentation + History
▪ Discharging sinus, 4 months duration
▪ Probed to 3cm but not bone, serous exudate
▪ Multiple courses antibiotics
▪ No improvement
▪ Painful at times
▪ Nil injury history
![Page 8: “Case Histories To Ponder” · NZWC CONFERENCE 2019 “Case Histories To Ponder” Difficult wounds in the diabetic foot Roger Grech Senior Podiatrist CMDHB](https://reader034.fdocuments.in/reader034/viewer/2022050400/5f7e22e9de3c6028f135304e/html5/thumbnails/8.jpg)
Assessment + Investigations
▪ DP and PT pulses palpable
▪ Mild sensation loss
▪ Deep swabs
▪ X-ray
![Page 9: “Case Histories To Ponder” · NZWC CONFERENCE 2019 “Case Histories To Ponder” Difficult wounds in the diabetic foot Roger Grech Senior Podiatrist CMDHB](https://reader034.fdocuments.in/reader034/viewer/2022050400/5f7e22e9de3c6028f135304e/html5/thumbnails/9.jpg)
Results
▪ Culture – Staph Epidermidis
▪ X-ray unremarkable for OM or RO FB
▪ Suspicious of a hidden FB or RL FB?
▪ Deep collection?
![Page 10: “Case Histories To Ponder” · NZWC CONFERENCE 2019 “Case Histories To Ponder” Difficult wounds in the diabetic foot Roger Grech Senior Podiatrist CMDHB](https://reader034.fdocuments.in/reader034/viewer/2022050400/5f7e22e9de3c6028f135304e/html5/thumbnails/10.jpg)
MRI
Sinus tract extending into plantar foot
Small collection, no osteomyelitis
Linear shaped FB
No sinus to plantar skin seen
REFERRED ORTHOPAEDICS
![Page 11: “Case Histories To Ponder” · NZWC CONFERENCE 2019 “Case Histories To Ponder” Difficult wounds in the diabetic foot Roger Grech Senior Podiatrist CMDHB](https://reader034.fdocuments.in/reader034/viewer/2022050400/5f7e22e9de3c6028f135304e/html5/thumbnails/11.jpg)
Results
▪ Two small metal fragments removed from entrance to sinus
▪ Each measuring approximately 3 x 2mm
▪ Shiny opaque surfaces
▪ Aluminium fragments?
![Page 12: “Case Histories To Ponder” · NZWC CONFERENCE 2019 “Case Histories To Ponder” Difficult wounds in the diabetic foot Roger Grech Senior Podiatrist CMDHB](https://reader034.fdocuments.in/reader034/viewer/2022050400/5f7e22e9de3c6028f135304e/html5/thumbnails/12.jpg)
Results
![Page 13: “Case Histories To Ponder” · NZWC CONFERENCE 2019 “Case Histories To Ponder” Difficult wounds in the diabetic foot Roger Grech Senior Podiatrist CMDHB](https://reader034.fdocuments.in/reader034/viewer/2022050400/5f7e22e9de3c6028f135304e/html5/thumbnails/13.jpg)
Management
Improvement noted but still not healed completely
▪ Broad spectrum antibiotics
▪ Optimise blood glucose control
▪ Open footwear
▪ Awaiting orthopaedic appointment - exploratory surgery
- debridement
![Page 14: “Case Histories To Ponder” · NZWC CONFERENCE 2019 “Case Histories To Ponder” Difficult wounds in the diabetic foot Roger Grech Senior Podiatrist CMDHB](https://reader034.fdocuments.in/reader034/viewer/2022050400/5f7e22e9de3c6028f135304e/html5/thumbnails/14.jpg)
Case 3
51 year old female
Type 2 diabetes (HbA1c 46)
Obesity BMI 45
Cauda Equina syndrome (2003)-lumbar herniated disc
Discectomy L 4-5
Peripheral neuropathy and L foot drop
![Page 15: “Case Histories To Ponder” · NZWC CONFERENCE 2019 “Case Histories To Ponder” Difficult wounds in the diabetic foot Roger Grech Senior Podiatrist CMDHB](https://reader034.fdocuments.in/reader034/viewer/2022050400/5f7e22e9de3c6028f135304e/html5/thumbnails/15.jpg)
Presentation + History
▪ Non healing ulcer, 3 months duration
▪ Pus draining from ulcer
▪ Ulcer communicating to sinus tract
▪ Covered with thick callous
▪ Probed to 2 cm
▪ No history of injury
![Page 16: “Case Histories To Ponder” · NZWC CONFERENCE 2019 “Case Histories To Ponder” Difficult wounds in the diabetic foot Roger Grech Senior Podiatrist CMDHB](https://reader034.fdocuments.in/reader034/viewer/2022050400/5f7e22e9de3c6028f135304e/html5/thumbnails/16.jpg)
Presentation
![Page 17: “Case Histories To Ponder” · NZWC CONFERENCE 2019 “Case Histories To Ponder” Difficult wounds in the diabetic foot Roger Grech Senior Podiatrist CMDHB](https://reader034.fdocuments.in/reader034/viewer/2022050400/5f7e22e9de3c6028f135304e/html5/thumbnails/17.jpg)
Assessment + Investigations
▪ Foot pulses easily palpable
▪ Severe Peripheral neuropathy
▪ Referred x-ray, radio-opaque FB?
▪ Deep swabs of sinus tract
▪ Prescribed Augmentin
![Page 18: “Case Histories To Ponder” · NZWC CONFERENCE 2019 “Case Histories To Ponder” Difficult wounds in the diabetic foot Roger Grech Senior Podiatrist CMDHB](https://reader034.fdocuments.in/reader034/viewer/2022050400/5f7e22e9de3c6028f135304e/html5/thumbnails/18.jpg)
Results
▪ X-ray unremarkable
▪ Wound responded well to antibiotics and debridement
▪ Bacteria cultured sensitive to Augmentin
…..but then deteriorated again
Cause
Undrained collection? radiolucent FB?
Consider USS or MRI?
![Page 19: “Case Histories To Ponder” · NZWC CONFERENCE 2019 “Case Histories To Ponder” Difficult wounds in the diabetic foot Roger Grech Senior Podiatrist CMDHB](https://reader034.fdocuments.in/reader034/viewer/2022050400/5f7e22e9de3c6028f135304e/html5/thumbnails/19.jpg)
Management
▪ Frequent debridement
▪ Off loading footwear
▪ Regular dressings by D/N
Careful exploration of sinus with probe
![Page 20: “Case Histories To Ponder” · NZWC CONFERENCE 2019 “Case Histories To Ponder” Difficult wounds in the diabetic foot Roger Grech Senior Podiatrist CMDHB](https://reader034.fdocuments.in/reader034/viewer/2022050400/5f7e22e9de3c6028f135304e/html5/thumbnails/20.jpg)
Management
▪ White soft tissue tubular structure removed from sinus -sent to pathology
▪ Inflamed epidermal inclusion cyst
![Page 21: “Case Histories To Ponder” · NZWC CONFERENCE 2019 “Case Histories To Ponder” Difficult wounds in the diabetic foot Roger Grech Senior Podiatrist CMDHB](https://reader034.fdocuments.in/reader034/viewer/2022050400/5f7e22e9de3c6028f135304e/html5/thumbnails/21.jpg)
Healed Wound
▪ Healed after 3 weeks
▪ No recurrence on F/U
![Page 22: “Case Histories To Ponder” · NZWC CONFERENCE 2019 “Case Histories To Ponder” Difficult wounds in the diabetic foot Roger Grech Senior Podiatrist CMDHB](https://reader034.fdocuments.in/reader034/viewer/2022050400/5f7e22e9de3c6028f135304e/html5/thumbnails/22.jpg)
Case 4
▪ 66 year Cook Island male
▪ Type 2 diabetes
▪ ESRF – Haemodialysis
▪ Peripheral neuropathy
▪ Obesity
▪ Gout
▪ Right forefoot amputation with skin graft
![Page 23: “Case Histories To Ponder” · NZWC CONFERENCE 2019 “Case Histories To Ponder” Difficult wounds in the diabetic foot Roger Grech Senior Podiatrist CMDHB](https://reader034.fdocuments.in/reader034/viewer/2022050400/5f7e22e9de3c6028f135304e/html5/thumbnails/23.jpg)
Presentation + History
▪ Large exophytic, verruca - like mass over stump
▪ Had been present for 6 months plus, not painful
▪ Highly exudating, malodorous
▪ Treated with antibiotics by GP
▪ Afebrile, no cellulitis
![Page 24: “Case Histories To Ponder” · NZWC CONFERENCE 2019 “Case Histories To Ponder” Difficult wounds in the diabetic foot Roger Grech Senior Podiatrist CMDHB](https://reader034.fdocuments.in/reader034/viewer/2022050400/5f7e22e9de3c6028f135304e/html5/thumbnails/24.jpg)
Presentation
![Page 25: “Case Histories To Ponder” · NZWC CONFERENCE 2019 “Case Histories To Ponder” Difficult wounds in the diabetic foot Roger Grech Senior Podiatrist CMDHB](https://reader034.fdocuments.in/reader034/viewer/2022050400/5f7e22e9de3c6028f135304e/html5/thumbnails/25.jpg)
Assessment + Investigations
▪ Deep swabs – polymicrobial
▪ Punch biopsy – inconclusive, Hypergranulosis, epithelial hyperplasia
▪ X-ray - no osteomyelitis
▪ Clinical diagnosis – possible Verrucous hyperplasia
▪ Differential Dx – Verrucous carcinoma
▪ Refer MDT - orthopaedics
![Page 26: “Case Histories To Ponder” · NZWC CONFERENCE 2019 “Case Histories To Ponder” Difficult wounds in the diabetic foot Roger Grech Senior Podiatrist CMDHB](https://reader034.fdocuments.in/reader034/viewer/2022050400/5f7e22e9de3c6028f135304e/html5/thumbnails/26.jpg)
X-Ray
![Page 27: “Case Histories To Ponder” · NZWC CONFERENCE 2019 “Case Histories To Ponder” Difficult wounds in the diabetic foot Roger Grech Senior Podiatrist CMDHB](https://reader034.fdocuments.in/reader034/viewer/2022050400/5f7e22e9de3c6028f135304e/html5/thumbnails/27.jpg)
Initial Management
• Lower bacterial burden of lesion
• a) Antibiotics (Augmentin and Ciprofloxacin)
• b) Iodosorb, absorptive secondary dressings
• Debridement (difficult due to bleeding)
• Compression bandaging and offloading
![Page 28: “Case Histories To Ponder” · NZWC CONFERENCE 2019 “Case Histories To Ponder” Difficult wounds in the diabetic foot Roger Grech Senior Podiatrist CMDHB](https://reader034.fdocuments.in/reader034/viewer/2022050400/5f7e22e9de3c6028f135304e/html5/thumbnails/28.jpg)
Conservative Management
![Page 29: “Case Histories To Ponder” · NZWC CONFERENCE 2019 “Case Histories To Ponder” Difficult wounds in the diabetic foot Roger Grech Senior Podiatrist CMDHB](https://reader034.fdocuments.in/reader034/viewer/2022050400/5f7e22e9de3c6028f135304e/html5/thumbnails/29.jpg)
Management Options
▪ Patient refused surgical intervention
▪ Wife also having dialysis - difficulty in driving
▪ Fearful of major amputation
▪ Did eventually consent to surgery
![Page 30: “Case Histories To Ponder” · NZWC CONFERENCE 2019 “Case Histories To Ponder” Difficult wounds in the diabetic foot Roger Grech Senior Podiatrist CMDHB](https://reader034.fdocuments.in/reader034/viewer/2022050400/5f7e22e9de3c6028f135304e/html5/thumbnails/30.jpg)
Surgical Management
▪ Excision of Verrucous hyperplasia
▪ Pathology report - Benign Verrucous Hyperplasia with superimposed chronic infection
▪ Bone trimming of medial cuneiform
▪ Achilles tendon lengthening
▪ Serial casting
![Page 31: “Case Histories To Ponder” · NZWC CONFERENCE 2019 “Case Histories To Ponder” Difficult wounds in the diabetic foot Roger Grech Senior Podiatrist CMDHB](https://reader034.fdocuments.in/reader034/viewer/2022050400/5f7e22e9de3c6028f135304e/html5/thumbnails/31.jpg)
Management - TCC
![Page 32: “Case Histories To Ponder” · NZWC CONFERENCE 2019 “Case Histories To Ponder” Difficult wounds in the diabetic foot Roger Grech Senior Podiatrist CMDHB](https://reader034.fdocuments.in/reader034/viewer/2022050400/5f7e22e9de3c6028f135304e/html5/thumbnails/32.jpg)
Management – Post surgical
![Page 33: “Case Histories To Ponder” · NZWC CONFERENCE 2019 “Case Histories To Ponder” Difficult wounds in the diabetic foot Roger Grech Senior Podiatrist CMDHB](https://reader034.fdocuments.in/reader034/viewer/2022050400/5f7e22e9de3c6028f135304e/html5/thumbnails/33.jpg)
Healing Wound
![Page 34: “Case Histories To Ponder” · NZWC CONFERENCE 2019 “Case Histories To Ponder” Difficult wounds in the diabetic foot Roger Grech Senior Podiatrist CMDHB](https://reader034.fdocuments.in/reader034/viewer/2022050400/5f7e22e9de3c6028f135304e/html5/thumbnails/34.jpg)
Healed Wound
![Page 35: “Case Histories To Ponder” · NZWC CONFERENCE 2019 “Case Histories To Ponder” Difficult wounds in the diabetic foot Roger Grech Senior Podiatrist CMDHB](https://reader034.fdocuments.in/reader034/viewer/2022050400/5f7e22e9de3c6028f135304e/html5/thumbnails/35.jpg)
Verrucous hyperplasia
▪ Cause unknown
▪ Possibly chronic infection, friction, chronic irritation?
▪ Oedema especially of stump amputations?
▪ More common after grafting?
▪ Well documented in oral surgery/dermatology literature
![Page 36: “Case Histories To Ponder” · NZWC CONFERENCE 2019 “Case Histories To Ponder” Difficult wounds in the diabetic foot Roger Grech Senior Podiatrist CMDHB](https://reader034.fdocuments.in/reader034/viewer/2022050400/5f7e22e9de3c6028f135304e/html5/thumbnails/36.jpg)
Take home message
![Page 37: “Case Histories To Ponder” · NZWC CONFERENCE 2019 “Case Histories To Ponder” Difficult wounds in the diabetic foot Roger Grech Senior Podiatrist CMDHB](https://reader034.fdocuments.in/reader034/viewer/2022050400/5f7e22e9de3c6028f135304e/html5/thumbnails/37.jpg)
Take home messageReasons for non-healing DFU include:▪ PVD?
▪ Deep Infection?
▪ Pressure combined with neuropathy?
▪ Biofilm?
▪ FB?
▪ Oedema?
▪ Cancerous change?
▪ Autoimmune, Vasculitic ulcers?
▪ Immuno-suppressive /cytotoxic medication?
▪ Poor blood glucose control
▪ Smoking……….Other?
![Page 38: “Case Histories To Ponder” · NZWC CONFERENCE 2019 “Case Histories To Ponder” Difficult wounds in the diabetic foot Roger Grech Senior Podiatrist CMDHB](https://reader034.fdocuments.in/reader034/viewer/2022050400/5f7e22e9de3c6028f135304e/html5/thumbnails/38.jpg)
Avoid Complacency
![Page 39: “Case Histories To Ponder” · NZWC CONFERENCE 2019 “Case Histories To Ponder” Difficult wounds in the diabetic foot Roger Grech Senior Podiatrist CMDHB](https://reader034.fdocuments.in/reader034/viewer/2022050400/5f7e22e9de3c6028f135304e/html5/thumbnails/39.jpg)
Embrace Challenges
![Page 40: “Case Histories To Ponder” · NZWC CONFERENCE 2019 “Case Histories To Ponder” Difficult wounds in the diabetic foot Roger Grech Senior Podiatrist CMDHB](https://reader034.fdocuments.in/reader034/viewer/2022050400/5f7e22e9de3c6028f135304e/html5/thumbnails/40.jpg)
Question
Which health professional is best suited to manage diabetic foot wounds?
![Page 41: “Case Histories To Ponder” · NZWC CONFERENCE 2019 “Case Histories To Ponder” Difficult wounds in the diabetic foot Roger Grech Senior Podiatrist CMDHB](https://reader034.fdocuments.in/reader034/viewer/2022050400/5f7e22e9de3c6028f135304e/html5/thumbnails/41.jpg)
AnswerAll of them!
Multidisciplinary Team
![Page 42: “Case Histories To Ponder” · NZWC CONFERENCE 2019 “Case Histories To Ponder” Difficult wounds in the diabetic foot Roger Grech Senior Podiatrist CMDHB](https://reader034.fdocuments.in/reader034/viewer/2022050400/5f7e22e9de3c6028f135304e/html5/thumbnails/42.jpg)
Thank You!