Offloading diabetic wounds
Gretchen Wellman
Description
Collection
Title:
Offloading diabetic wounds
Creator:
Gretchen Wellman
Date:
10/30/2013
Text:
Hello list--
I've taken over a 34 year old male patient and am looking for suggestions about further adjustments that might be made for offloading of wounds.
Background: thin 34 year old, diabetic, neuropathy, Charcot foot and knee, Celiac's disease, on dialysis (has to keep on lower flow or else reportedly his brain swells), multiple health conditions, edema, difficulty using his hands. According to one of his doctors, he was in such poor health and historically made bad decisions, that he didn't go through puberty until she stuck him in the hospital for 3 months at age 28 years to force proper nutrition, etc.
He has worn a left knee orthosis for several years and a left CROW since February 2012. He was doing relatively okay, didn't have wounds.
He uses a manual wheelchair and mainly propels himself pulling along with his heels, rather than using his hands; he has recently lost a pinky finger to necrosis and is in the process of likely losing his thumbs. From heel propulsion (he doesn't really walk), he developed a couple months ago a wound on his right heel-- the entire plantar surface and up the posterior as well. We modified a PRAFO and lifted him up so that entire area didn't touch and were successful for a time. Recently, we tried adjusting the lift as the crepe of the lift appeared to have caused him to develop a sore further distal also, despite all the soft fluffy lining; however, it appears now the lift is far enough distal due to the size of the heel wound, he is able to bring the heel down and rest it on the metal of the orthosis. These wounds, or at least the original heel one (this is the right side) have now developed osteomyelitis and the doctors are trying to decide how to address that.
Last week he had an angiogram and reacted badly, bleeding excessively to the point that he had to be taken to the ED by ambulance. He apparently bled until 2 am the next day so was bed-ridden for 3 days. He transferred 2 or 3 times each of those days but neglected to wear his orthoses. Naturally, he has developed a sore on the left (CROW wearing) heel, on both the plantar surface and the posterior, similar to how the right side started.
I talked with another clinician in my office and both my technicians at length, trying to figure out how to adjust the CROW as the physician requested. But we couldn't find a way, not that would be sufficient offloading while not causing another area of trouble. Same with the modified PRAFO. And the slippers his mother brought in to wear instead.
Even his physician (one of several) and nurse seem resigned and have told me he is just going to lose his legs soon. They are going to try and get him Prevalon boots for while he sleeps but what about the rest of the time? He is very resistant to getting an electric wheelchair and wants to stay mobile.
Thoughts? Would you make bilateral new CROW boots and really try to offload the heels? We don't want anything to touch but it seems wherever we try to offload, the next area that touches (despite graduation) develops a sore.
Please advise if you have any experience or suggestions.
Gretchen Wellman CO
Northern Orthopedics, Inc.
I've taken over a 34 year old male patient and am looking for suggestions about further adjustments that might be made for offloading of wounds.
Background: thin 34 year old, diabetic, neuropathy, Charcot foot and knee, Celiac's disease, on dialysis (has to keep on lower flow or else reportedly his brain swells), multiple health conditions, edema, difficulty using his hands. According to one of his doctors, he was in such poor health and historically made bad decisions, that he didn't go through puberty until she stuck him in the hospital for 3 months at age 28 years to force proper nutrition, etc.
He has worn a left knee orthosis for several years and a left CROW since February 2012. He was doing relatively okay, didn't have wounds.
He uses a manual wheelchair and mainly propels himself pulling along with his heels, rather than using his hands; he has recently lost a pinky finger to necrosis and is in the process of likely losing his thumbs. From heel propulsion (he doesn't really walk), he developed a couple months ago a wound on his right heel-- the entire plantar surface and up the posterior as well. We modified a PRAFO and lifted him up so that entire area didn't touch and were successful for a time. Recently, we tried adjusting the lift as the crepe of the lift appeared to have caused him to develop a sore further distal also, despite all the soft fluffy lining; however, it appears now the lift is far enough distal due to the size of the heel wound, he is able to bring the heel down and rest it on the metal of the orthosis. These wounds, or at least the original heel one (this is the right side) have now developed osteomyelitis and the doctors are trying to decide how to address that.
Last week he had an angiogram and reacted badly, bleeding excessively to the point that he had to be taken to the ED by ambulance. He apparently bled until 2 am the next day so was bed-ridden for 3 days. He transferred 2 or 3 times each of those days but neglected to wear his orthoses. Naturally, he has developed a sore on the left (CROW wearing) heel, on both the plantar surface and the posterior, similar to how the right side started.
I talked with another clinician in my office and both my technicians at length, trying to figure out how to adjust the CROW as the physician requested. But we couldn't find a way, not that would be sufficient offloading while not causing another area of trouble. Same with the modified PRAFO. And the slippers his mother brought in to wear instead.
Even his physician (one of several) and nurse seem resigned and have told me he is just going to lose his legs soon. They are going to try and get him Prevalon boots for while he sleeps but what about the rest of the time? He is very resistant to getting an electric wheelchair and wants to stay mobile.
Thoughts? Would you make bilateral new CROW boots and really try to offload the heels? We don't want anything to touch but it seems wherever we try to offload, the next area that touches (despite graduation) develops a sore.
Please advise if you have any experience or suggestions.
Gretchen Wellman CO
Northern Orthopedics, Inc.
Citation
Gretchen Wellman, “Offloading diabetic wounds,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 2, 2024, https://library.drfop.org/items/show/235700.
