1 A Team Approach to Wound Care on the Lower Limb A Physical Therapist’s Perspective James G. Spahn, MD, FACS Sharon Lucich, PT , CWS Jaimee Haan, PT, CWS 1 FACTS FACTS Pressure ulcers are the result of an ischemic event, and not a crush injury Soft tissue distortion leads to Ischemic necrosis (pressure ulcer). 2 FACTS FACTS Contact with a support surface causes either volumetric support of the body or distortion of the soft tissue trapped between the bony prominence and the support surface. Since the body is three-dimensional, volumetric support (flotation) is needed to maintain proper tissue orientation. 3
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FACTSFACTS - EHOB · FACTSFACTS Pressure ulcers are ... –Tibia –Fibula 42 Bones of the Ankle and Foot ... compensate for a bone deformity, deforming forces, or forces absent from
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1
A Team Approach to Wound Care
on the Lower LimbA Physical Therapist’s Perspective
James G. Spahn, MD, FACS
Sharon Lucich, PT , CWS
Jaimee Haan, PT, CWS
1
FACTSFACTS
Pressure ulcers are the result of an
ischemic event, and not a crush injury
Soft tissue distortion leads to
Ischemic necrosis (pressure ulcer).
2
FACTSFACTS
Contact with a support surface causes
either volumetric support of the body or
distortion of the soft tissue trapped
between the bony prominence and the
support surface.
Since the body is three-dimensional,
volumetric support (flotation) is
needed to maintain proper tissue
orientation.
3
2
FACTSFACTS
Nutritionally and mobility impaired
patients are at risk for developing
pressure ulcers.
4
FACTSFACTS
Pressure ulcers may start immediately,
but often are not recognized until 3-7
days later.
High incidence of pressure ulcers may
occur on bed, surgery, ER, transportation
cart, and seating surfaces.
5
FACTSFACTS
Continuum of care is needed during
the acute, sub-acute, and chronic
levels of care.
Patients at risk are usually discharged
to rehab, since they are not
rehabilitated at time of discharge.
6
3
FACTSFACTS
Protocols decrease incidence by 50% 1
Usage of pressure-reducing devices
alone can cause an increase in
incidence.2
1. Moody BL, Fanale JE, Thompson M. Vaillancourt D, Symonds G, Bonasoro C. Impact of staff
education on pressure sore development in elderly hospitalized patients. Archives of Internal
Medicine. 1988; 148:2241-2243.
2. Lyder CH, Preston J, Grady JN, Scinto J, Allman R, Bergstrom N, Rodeheaver G. Quality of care
for hospitalized medicare patients at risk for pressure ulcers. Archives of Internal Medicine. 2001;
161: 1549-1544.
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Clinical Protocols
NutritionMobilization
Ambulate
TurnPassive Range of Motion
Support SurfaceBed, Chair, Cart, Emergency Room, Operating Room
Incontinence CareWound CareContinuum of Care
Treatment of other generalmedical conditions
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FACTSFACTS
Heel ulcers constitute 30% of all
pressure ulcers in hospital settings.
The heel consistently ranks as the
second most common location for
pressure ulcers.
Acute care heel prevalence is between
8-17% (1992)
15-23% (1997)
(Dekeyser, Dejarger, Meyst and Evers, 1994)
(Barczak, Barnett, Childs, Bosley, 1997)
9
4
FACTSFACTS
Heel ulcers constitute 30% of all
pressure ulcers in hospital settings.
The heel consistently ranks as the
second most common location for
pressure ulcers.
Acute care heel prevalence is between
8-17% (1992)
15-23% (1997)
(Dekeyser, Dejarger, Meyst and Evers, 1994)
(Barczak, Barnett, Childs, Bosley, 1997)
What’s Wrong With This Picture?
10
Hospital Bed Simulation
Pressure = 19mmHg
(3” high density foam, air mattress and bed. Clothing)
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12
5
13
60
50
40
30
20
10
New Pressure UlcersIschial Tuberosity
Heel
Board 2” Foam 3” Foam 4” Foam Static
Air
Air on
FoamStrain % on Various Surface Type
50.1
10
4244
8.5
24.525.1
11.3
31.1
25
10.1
27.9
83
11.7
8
1.2
10.5
Greater Trochanter
Source: “Hospital Replacement
Mattresses.” “Journal of ET Nursing.”
Johnson, Daily & Franciscus.
Heel
Greater
Trochanter
Ischial Tuberosity
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Criteria for lower extremity protectionCriteria for lower extremity protection
In a horizontal In a horizontal postionpostion::
1.1. Provide volumetric support of calfProvide volumetric support of calf
Biomechanics of the Lower Biomechanics of the Lower ExtremityExtremity
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Joint MotionJoint Motion
• Range of Motion: (ROM)
– The amount of motion available at a joint
• Active Range of Motion (AROM):
– Amount of motion available at a joint by a
subject during unassisted voluntary
movement
• Passive Range of Motion (PROM):
– Amount of motion available at a joint attained
by an examiner without the assistance of the
subject
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• Goniometry:
– Measurement of joint
angles created by the
bones of the body
• Goniometer:
– Tool used for
goniometry
0o
45o
Knee ROM
30o
0o
Ankle ROM
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ROM of the HipROM of the Hip
• Flexion:
– Bending of the hip joint
• Extension:
– Straightening of the hip
Joint
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49
ROM of the HipROM of the Hip
• Abduction:
– Movement of the femur away
from midline
• Adduction:
– Movement of the femur
towards midline
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ROM of the HipROM of the Hip
• External (or Lateral) Rotation:– Rotation of the femur away
from midline
• Internal (or Medial) Rotation:– Rotation of the femur toward
midline
• Neutral Position: – No internal or external rotation
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ROM of the KneeROM of the Knee
• Flexion:
– Bending of the knee
• Extension:
– Straightening of the kneeHoppenfeld, Stanley: Physical Examination of the
Spine and Extremities, 1976
Hyperextension:Knee extension beyond
neutral
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Common Types of Knee Common Types of Knee DeformityDeformity
• Genu Varum:
• Genu Valgum:
• Genu Recurvatum:
Hoppenfeld, Stanley: Physical Examination of the Spine and Extremities, 1976
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ROM of the Foot and AnkleROM of the Foot and Ankle
• Plantarflexion:
– Ankle joint flexion
– Movement of the bottom of
the foot in the caudal (tail)
and posterior direction
• Dorsiflexion:
– Ankle joint extension
– Movement of the top of the
foot in the cranial (head)
and anterior direction
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ROM of the Foot and ROM of the Foot and AnkleAnkle
• Abduction:
– Movement in a sideways
direction away from
midline of the foot
• Adduction:
– Movement in a sideways
direction towards midline
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ROM of the Foot and AnkleROM of the Foot and Ankle
• Pronation:
– Rotation of the foot so that the sole of the foot faces a lateral (away from midline of the body) direction
• Supination:
– Rotation of the foot so that the sole of the foot faces a medial (toward midline of the body) direction
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ROM of the Foot and AnkleROM of the Foot and Ankle
• Inversion:
– A combination of
supination and
adduction of the foot
• Eversion:
– A combination of
pronation and
abduction
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Ankle AlignmentAnkle Alignment
• Neutral Position:– The ankle is considered to be
“in neutral” when the foot is at a right angle with the tibia
• Subtalar Neutral:– The point at which the
subtalar joint is fully supinated and then carried two-thirds of the way through maximum pronation
Relevance: when positioning a foot in a splint Relevance: when positioning a foot in a splint the goal is to achieve neutral alignment of the the goal is to achieve neutral alignment of the ankle and the ankle and the subtalarsubtalar jointjoint
20
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Gait Cycle
60
Standing Alignment and Standing Alignment and BalanceBalance
Base of Support
21
61
Phases of Gait CyclePhases of Gait CycleSTANCE PHASE SWING PHASE
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Abnormal Gait PatternsAbnormal Gait Patterns
• Foot slap
– Weak dorsiflexors
cause foot to slap
down
– Occurs at the
beginning of heel
strike
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Abnormal Gait PatternsAbnormal Gait Patterns
• Toe scuff
– Lack of dorsiflexion
– Occurs during midswing
22
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Abnormal Gait Patterns
• High steppage gait
– Loss of dorsiflexion
– Inability to decelerate
dorsiflexors
– Knee lifts higher than normal
to allow foot to clear the floor
– Occurs during midswing
• Leg Length discrepancy ?
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Abnormal Gait PatternsAbnormal Gait Patterns
• Hip hike
• Leg Length discrepancy?
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Abnormal Gait PatternsAbnormal Gait Patterns
• Balance issues
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Common Foot/Ankle Common Foot/Ankle
Impairments Requiring the Impairments Requiring the
Use of an AFO Use of an AFO
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Foot DropFoot Drop
•• An abnormal neuromuscular An abnormal neuromuscular condition of the lower leg and condition of the lower leg and foot characterized by an inability foot characterized by an inability to to dorsiflexdorsiflex or or evertevert the footthe foot
•• May be due to damage to the May be due to damage to the Common Common PeronealPeroneal Nerve or Nerve or dorsiflexorsdorsiflexors
•• AFO can be used for treatment if AFO can be used for treatment if surgery not an optionsurgery not an option
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Foot Drop Foot Drop (cont)(cont)
• Splinting Philosophy
– Stabilize ankle in neutral position to maintain
functional ankle range of motion to allow
standing and ambulation (walking)
– Provide medial and lateral stabilization of the
hip joint (Use stabilization bar if available on
the AFO)
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Plantarflexion Contracture
• Abnormal, usually permanent, condition of the ankle joint characterized by plantarflexion and fixation; caused by atrophy and shortening of muscle fibers (“heel cord”)
• Goal: Maintenance of current ROM to enable adequate skin care and functional use
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SpasticitySpasticity
• A state of increased muscular tone with
exaggeration of tendon reflexes
• Common in patients with closed head
injuries, spinal cord injuries, cerebral palsy
or stroke
• Can cause deformity and limit functional
movement
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Spasticity Spasticity (cont)(cont)
• Splinting Philosophy
– Apply mechanical force to correct or prevent
contractures
• Shortened muscles cause increased muscle tone;
splinting at the ankle puts the gastroc/achilles on a
prolonged stretch allowing lengthening to occur in
the collagen of the soft tissue and re-form to the
appropriate length
– Provides sensory stimulation which alters
muscle tone to promote normal movement
patterns
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Spasticity (cont)
• Splinting Philosophy
– Precautions
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Plantar FasciitisPlantar Fasciitis
• Repetitive micro-trauma to Plantar Fascia (fibrous band that supports the arch of the foot)
• Causes pain on plantar surface of heel and medial aspect of foot with weight bearing
– An ill-fitting ankle-foot orthosis can cause harm to the patient
– The ankle joint should be positioned in the splint at the correct therapeutic angle
– When a patient wears an AFO with padding in supine (lying on their back), the distal tibia is elevated relative to the proximal tibia and femur; This encourages knee hyperextension