reply summary Bilateral Heel Ulcers part 1
Ted A. Trower
Description
Collection
Title:
reply summary Bilateral Heel Ulcers part 1
Creator:
Ted A. Trower
Date:
7/11/2000
Text:
The question was:
I got a tough referral the other day and could use some ideas.
The gentleman is a nursing home resident (on a part A stay for folks in the
USA) with severe bilateral heel ulcers. The ulcers are on the plantar
surface and cover the entire region of the heel pad plus a little more. He
is a long term diabetic with neuropathy and vascular compromise. The entire
length of the leg below the knee is very edematous. He is also moderatly
obese. He is up in a wheelchair but takes a few steps every time he goes
into the bathroom. He is currently wearing kerlix dressings under slipper
socks. He is too unstable for something like IPOS heel relief shoes. He is
alert but suffers enough encephalopathy that I doubt he would remember or
follow instructions to remain on bed rest. I also doubt the nursing home
has the staff to enforce it.
I've looked at the usual PRAFO type devices but do not believe they would be
effective in protecting the plantar surface of the heel when standing. I'm
leaning towards placing him in bilateral healing boots of the total contact
bivalve AFO type but seem to remember reading a study stating they were not
very effective on plantar heel ulcers??????? Also given that he is on a
part A Medicare stay the nursing home will have to pay for them and I'm
expecting strong resistance to the cost. Thirdly I doubt just how stable
this individual would be in attempting to stand and walk with these devices
on both feet. Perhaps it would be one way to enforce bed rest but I
certainly do not want to cause him to fall. I've told the nurse and the PT
that my impression is this gentleman would be healthier and more functional
with bilateral BK amputations but no one is ready to hear that yet.
-----
Replys follow:
-------------------------------------------------------------------------------
the classic solid ankle AFO may help distribute force at heel strike. A
vascular consult may also be in order.
Wade Bader, CPO
-------------------------------------------------------------------------------
I would also tent towards the total contact below knee castings or
removable padded plaster boots. The plaster boots would have holes cut
through for pressure relief on the heels, I tent to find this works best for
me.
As to the patient being unstable, the plaster could be flared out to
provide a wider base for support.
If the nursing home is concerned over the price, then they should
consider the eventual cost which could easily arise if this problem is not
solved quickly! (Although I appreciate that this is not always easy to do)
Yours - T Juden, Orthotist. MBAPO, ISPO.
-------------------------------------------------------------------------------
Ted, seems like you're fighting from every angle here. Very tough
situation- for you and for this poor gentleman! Have you considered a PTB
AFO type device? My initial thought would be to make it bi-valved and add
soling material to the base for transfer stability and short ambulation.
You could even incorporate a PRAFO style heel into this providing posterior
relief while on bed rest. If he ambulates infrequently, this may be
sufficient as well as stable for him. Not really a cost containment
approach, though. Just food for thought. Best of luck.
Joan Cestaro
-------------------------------------------------------------------------------
TED ...the Neuropathic Walker plastic clamshell design extended proximally to
include a PTB design may work.Expensive trial for limited ambulator.A
Clamshell PTB design with metal uprights attached to a reinforced protective
shoe (w/surgical opening) is along the same line. The big question I ask is,
how did his ulceration progress so much. Lack of care or very weak and thin
skin is evident. Nothing other than acute wound management and very limited
weight bearing may be the correct answer..
John
-------------------------------------------------------------------------------
Ted A. Trower C.P.O.
A-S-C Orthotics & Prosthetics
Jackson, MI, USA
I got a tough referral the other day and could use some ideas.
The gentleman is a nursing home resident (on a part A stay for folks in the
USA) with severe bilateral heel ulcers. The ulcers are on the plantar
surface and cover the entire region of the heel pad plus a little more. He
is a long term diabetic with neuropathy and vascular compromise. The entire
length of the leg below the knee is very edematous. He is also moderatly
obese. He is up in a wheelchair but takes a few steps every time he goes
into the bathroom. He is currently wearing kerlix dressings under slipper
socks. He is too unstable for something like IPOS heel relief shoes. He is
alert but suffers enough encephalopathy that I doubt he would remember or
follow instructions to remain on bed rest. I also doubt the nursing home
has the staff to enforce it.
I've looked at the usual PRAFO type devices but do not believe they would be
effective in protecting the plantar surface of the heel when standing. I'm
leaning towards placing him in bilateral healing boots of the total contact
bivalve AFO type but seem to remember reading a study stating they were not
very effective on plantar heel ulcers??????? Also given that he is on a
part A Medicare stay the nursing home will have to pay for them and I'm
expecting strong resistance to the cost. Thirdly I doubt just how stable
this individual would be in attempting to stand and walk with these devices
on both feet. Perhaps it would be one way to enforce bed rest but I
certainly do not want to cause him to fall. I've told the nurse and the PT
that my impression is this gentleman would be healthier and more functional
with bilateral BK amputations but no one is ready to hear that yet.
-----
Replys follow:
-------------------------------------------------------------------------------
the classic solid ankle AFO may help distribute force at heel strike. A
vascular consult may also be in order.
Wade Bader, CPO
-------------------------------------------------------------------------------
I would also tent towards the total contact below knee castings or
removable padded plaster boots. The plaster boots would have holes cut
through for pressure relief on the heels, I tent to find this works best for
me.
As to the patient being unstable, the plaster could be flared out to
provide a wider base for support.
If the nursing home is concerned over the price, then they should
consider the eventual cost which could easily arise if this problem is not
solved quickly! (Although I appreciate that this is not always easy to do)
Yours - T Juden, Orthotist. MBAPO, ISPO.
-------------------------------------------------------------------------------
Ted, seems like you're fighting from every angle here. Very tough
situation- for you and for this poor gentleman! Have you considered a PTB
AFO type device? My initial thought would be to make it bi-valved and add
soling material to the base for transfer stability and short ambulation.
You could even incorporate a PRAFO style heel into this providing posterior
relief while on bed rest. If he ambulates infrequently, this may be
sufficient as well as stable for him. Not really a cost containment
approach, though. Just food for thought. Best of luck.
Joan Cestaro
-------------------------------------------------------------------------------
TED ...the Neuropathic Walker plastic clamshell design extended proximally to
include a PTB design may work.Expensive trial for limited ambulator.A
Clamshell PTB design with metal uprights attached to a reinforced protective
shoe (w/surgical opening) is along the same line. The big question I ask is,
how did his ulceration progress so much. Lack of care or very weak and thin
skin is evident. Nothing other than acute wound management and very limited
weight bearing may be the correct answer..
John
-------------------------------------------------------------------------------
Ted A. Trower C.P.O.
A-S-C Orthotics & Prosthetics
Jackson, MI, USA
Citation
Ted A. Trower, “reply summary Bilateral Heel Ulcers part 1,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 26, 2024, https://library.drfop.org/items/show/214667.
