1. Foot and Leg Wound Management: Medical Issues
Dr. Todd Yip MSc MD FRCPC
Dine and Learn Event
Victoria Division of Family Practice
January 28, 2014

2. Declaration
One Bracing is an orthotic, bracing, and splinting office within Rebalance MD clinic

3. Foot and Leg Ulcer Clinic
RJH Memorial Pavilion
40-50 new referrals per month
Nurses, Pedorthist, Orthotist, Physician, Surgeon
Not open Mondays, some Friday PM
Referrals must be via Central Intake
Recommend fax copy of referral to FLUC

4. Peripheral Vascular Disease and Compression
Dr. Todd Yip MSc MD FRCPC
Victoria Division of Family Practice
Dine and Learn Event
January 28, 2014

5. Edema
Lower limb edema control is vital to heal wounds and to prevent recurrent ulceration.
How much compression would be reasonable?
What is a reasonable to compression management?

6. PVD Work-up Arterial Venous **Renal function (eGFR >60)
**Resting arterial doppler U/S (includes ABI)
ABI (with doppler study
**CTA Abdo Aorta + runoff (preferred)
Conventional unilateral angiogram
MR Angiography
**key items
Venous
Reflux (valve competence)
Deep veins, Superficial veins, perforators

7. Ankle Brachial Index/Doppler Ultrasound
<0.4 Severe disease (rest pain)
Mild to moderate disease
Normal
>1.3 Poorly compressible vessels
Age and diabetes – main confounders
Doppler
Waveform (flattens with disease)
Triphasic Normal
Biphasic Mild disease
Monophasic Severe disease
Localizes occlusive disease
Eg. Monophasic popliteal, dorsalis pedis, posterior tibial = above knee stenosis
Toe pressure
>30 mmHg
Predicts healing in non-diabetic
>50 mmHg
Predicts healing in diabetic

8. Ankle Brachial Index Sensitivity: 70-90% Specificity: 65-95%
Lower in elderly or diabetics
Specificity: 65-95%
Khan TH et al. Critical Review of the Ankle Brachial Index. Current Cardiology Reviews, 2008, 4,

9. ABI/Toe Pressure

10. ABI/Toe Pressure

11. Approach to Compression
Avoid compression (generally)
Severe PAD; ABI <0.4
Low compression (8-15 mmHg)
ABI >0.5
Pure venous + leg edema +/- significant drainage
Needs dressing, not socks
Mixed PVD
Medium compression (15-20 mmHg)
Mixed PVD, if edema control reasonable
If tolerating low compression
Try adding low compression sock to low compression dressing to graduate

12. Approach to Compression
High compression
At least mmHg compression
Strong, palpable pulses, normal ABI; No risk factors
Pure venous disease, mild edema
?Local dressing + compression sock vs. compression dressing
Depends on clinical picture/practical options
Trial and (hopefully not) error approach
If dressings, change 2 to 3 x per week

13. Practical Considerations
The application of compression dressings (or complex dressing) is highly variable
Socks must be hand-washed and hung to dry
Socks must be less than 6-8 months old (of total daily use)
Socks on in the AM, off in the PM, unless patient sleeps in chair
Dressing and sock costs are often not covered in community

14. Some Compression Dressings
Modified Unna’s boot +/- tensor
Less than 10mmHg
Light options: local dressing + tubifast (blue- or yellow-line, or tubigrip)
Coban 2 lite – mmHg
Coban 2 – mmHg

15. Some Compression Options
If no ulcer or nearly healed, then compression stockings:
8-15 mmHg (e.g. “Diabetic sensifoot”)
15-20 mmHg intermediate
20-30 mmHg venous insufficiency, some PAD
30-40 mmHg lymphedema
40-50 mmHg young venous insufficiency
Some patients can use remarkably high compression safely

16. Compression Stocking Practical Tips
Layered lower level compression stockings for increased compliance/ease of management and cost savings
10 mmHg stocking liner
10 mmHg ankle-high “socklet”
Open-toed or zippered socks
Sock donning gadgets
Home supports as required for dressing

17. Infection Dr. Todd Yip MSc MD FRCPC
Victoria Division of Family Practice
Dine and Learn Event
January 28, 2014

18. Work-up - Foot X-ray +/- x-ray in 3 weeks CBC, CRP, renal function
Bone scan (debatable role – non-specific)
“add infection label if +”
WBC label if <3/12
Gallium if >3/12
Indicate duration of ulcer and if patient on antibiotics on requisition
MRI - ?debatable role
Wound cultures can be helpful or misleading

19. Infection Legs Mostly clinical diagnosis
?Cellulitis vs. ?Stasis dermatitis vs. ?Ostemyelitis
Essentially the same work up as feet

20. Diabetic Foot Infections (DFI)
Mostly polymicrobial
Aerobic GPC, especially staphylococci
Aerobic GNB, if chronic
Anaerobes, if ischemic or necrotic
Foul odour of necrosis +/- pseudomonas

21. Reasonable Empiric Antibiotics
1st line
Keflex (500 mg BID-QID)
Clindamycin ( mg TID)
2nd line
Clindamycin + cipro ( mg OD-BID)
Clavulin (500 mg TID/875 mg BID)
If MRSA
Clindamycin, Bactrim (1 DS tab BID), or Doxycycline (100 mg BID)
Note: clindamycin requires no adjustment for renal function and covers MRSA!

22. Parenteral Antibiotics
Suggested Indications
Failed oral antibiotics
Abscess or ?abscess (surgical consult pending)
Sepsis
Dialysis
Side effects from oral antibiotics
Impaired immune response
Past response of frequent flyers
?Non-adherence to oral medications?
“No data support the superiority of any specific antibiotic agent or treatment strategy, route, or duration of therapy”
Lipsky et. al., 2012 Infectious Diseases Society of America Clinical Practice Guideline for the Diagnosis and Treatment of Diabetic Foot Infections. Clinical Infectious Diseases 2012;54(12):

23. Imaging for Osteomyelitis Details
Modality
Sensitivity
(%)
Specificity
X-ray
43 to 75
65 to 83
Bone scan
Technetium-99m methylene diphosphonate
69 to 100
38 to 82
Gallium-67 citrate scan
25 to 80
67 to 85
WBC Scan Technetium-99m hexamethyl-propyleneamine oxime-labeled 90
80 to 90
MRI
82 to 100
75 to 96
Pineda  C, Vargas  A, Rodriguez  AV.  Imaging of osteomyelitis: current concepts.  Infect Dis Clin North Am.  2006;20(4):789–825.
Termaat  MF, Raijmakers  PG, Scholten  HJ, Bakker  FC, Patka  P, Haarman  HJ.  The accuracy of diagnostic imaging for the assessment of chronic osteomyelitis: a systematic review and meta-analysis.  J Bone Joint Surg Am.  2005;87(11):2464–2471.
Kapoor  A, Page  S, Lavalley  M, Gale  DR, Felson  DT.  Magnetic resonance imaging for diagnosing foot osteomyelitis: a meta-analysis.  Arch Intern Med.  2007;167(2):125–132

24. Dermatology and Diabetes: Something Different?
Dr. Todd Yip MSc MD FRCPC
Victoria Division of Family Practice
Dine and Learn Event
January 28, 2014

25. Skin Manifestations of Diabetes
Type 1
Periungal telangiectasia
Necrobiosis lipoidica diabetacorum
Bullosis diabeticorum
Vitiligo
Lichen ruber planus
Type 2
Yellow nails
Diabetic thick skin
Acrochordons (skin tags)
Diabetic dermopathy
Skin spots and pigmented pretibial papules
Acanthosis nigricans
Acquired perforating dermatosis
Calciphylaxis
Eruptive xanthoma
Granuloma annulare

26. Skin Manifestations of Drugs
A number of reactions, too many to list
Van hattem, Bootsma AH, Thio HB. Cleveland Clinic Journal of Medicine: 75(11):

27. Three Recent Cases

31. My Main Differential Diagnosis
Dry skin (autonomic)
Fungus/tinea
??Psoriasis
??Something else that responds to topical steroid
If psoriasis, then it is recommended not to debride
So, confirming a diagnosis will affect the treatment approach (i.e. it affects management)

32. ?Psoriasis
Usually 2-3 referrals per to Dr. Telford, RJH Psoriasis Clinic dermatologist for “?Psoriasis not previously diagnosed?”
For estimated >95% of referrals, Dr. Telford agrees psoriasis – may or may agree with foot involvement
Prevalence = 2-4% general population
Prevalence among patients with diabetes?
Disclaimer: Dr. Telford’s consultation is pending for these cases.

33. Recent Literature: Psoriasis-Diabetes Link
Independent risk factor in the development of T2DM
Population-based cohort study (n=108132)
HR 1.14 (mild psoriasis); 1.30 (severe psoriasis)
Arch Dermatol. 2012;148(9):
Associated with an increased prevalence and incidence of diabetes
Systematic review and meta-analysis
27 Cohort, case-control, and cross-sectional studies from
Prevalence OR 1.59 (1.97 if severe psoriasis); Incidence RR 1.27
JAMA Dermatol. 2013; 149(1)84-91.

34. Questions Is the reverse true? That is,
Is the incidence and prevalence of psoriasis higher amongst those with diabetes?
Is diabetes and independent risk factor for psoriasis?
Is psoriasis more prevalent among those with “severe” diabetes? Or, those who have or at high risk of foot ulcers?

35. Three Recent Cases

36. Simple Treatment Approach
If unsure, consider treat with least potentially harmful agent first
Moisturizer
Hydrophilic petrolatum
Atrac-Tain
Anti-fungal
Anti-dandruff shampoo foot wash
Lamisil 1% OD
Steroid ointment
Clobetasol 0.05% OD (affected areas only)
Dermatology referral