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ORTHOPEDICS CASEWRITEUP CASE NO: 1

CASE WRITE-UP

YEAR 4FACULTY OF MEDICINE

UNIVERSITI TEKNOLOGI MARA

ORTHOPEDICS POSTING

CONFIDENTIAL

NAME : HAKIMAH KHANI BINTI SUHAIMIMATRIC NO : 2008409718YEAR OF STUDY : 4SESSION : 2011/2012SUPERVISOR : DR. YOHAN A KHIRUSMAN

UNIVERSITI TEKNOLOGI MARA/FACULTY OF MEDICINE/MBBS220/HAKIMAHKHANISUHAIMI 1


DEMOGRAPHIC DETAILSPatient’s Initial: Mrs. NIMRN: 00143343Sex: FemaleWard: Selayang Hospital, Ward 6C/Bed 4Age: 42 years oldReligion: IslamRace: MalayAddress: Selayang, SelangorOccupation: HousewifeDate of Admission: 15th November 2011 Date of Clerking: 16th November 2011 Date of Discharge: 25th December 2011History taken from: The patient

PRESENTING COMPLAINTMrs. NI, a 42-year-old Malay lady, with a background history of uncontrolled diabetes mellitus was admitted to Selayang Hospital on 15th November 2011 due to painful right foot ulcer 4 days after undergoing wound debridement.

HISTORY OF PRESENTING ILLNESSShe was otherwise well until 3 weeks prior to admission when she noticed an

ulcer at her right foot due to shoe scuffing. Initially, the ulcer was small, about 1cm in diameter, located at the lateral aspect of the right 5th toe, associated with localized mild pain and foul-smelling discharge, swelling and redness of the surrounding area, difficulty in walking and a low-grade fever.

One week later, the condition did not improve; hence she went to seek for leech therapy. The swelling was reduced, but continuous bleeding was developed after the therapy. Immediately, she went to ED Selayang and emergency wound debridement was done, leaving a bigger wound at the dorsal and lateral aspects of the right foot. She was then discharged home on the same day (due to family matters) with antibiotics and told to do daily dressing at nearby GP.

On Day 4 post-wound debridement, the GP told her that the wound was poorly healed with presence of pus and referred her to ED Selayang. She went to the ED, where an emergency wound re-debridement was done. She was then admitted to Ward 6C.

Upon further questioning, this was the first episode of ulcer. She denies any other treatment for foot. However, she noticed having pins and needles of glove and stocking distribution, dryness of the skin at the peripheries since one year ago. She denies any rest or night pains.



SYSTEMIC REVIEWNo headache, no syncope, no cough, no flu, no SOB, no chest pain, no palpitation, no orthopnea, no paroxysmal nocturnal dyspnea, no reduced effort tolerance, no polyuria/oliguria/dysuria, no polydipsia, no abnormal thirst, no abdominal pain, no vomiting, no diarrhea, no deterioration of vision

PAST MEDICAL HISTORYShe was diagnosed to have DM for the past 13 years and is undergoing follow up at KK Sg Tua every 3 months. Before the current admission to Selayang Hospital, she was on oral hypoglycemic agents (glibenclamide 10mg BD and metformin 10mg BD). According to her, the capillary blood glucose levels were poorly controlled even though she was compliant to the drugs (she monitors her blood glucose everyday). Recently, her morning capillary blood glucose was >20 mmols even though she claimed that she only ate biscuits the night before.

Early this year, she was diagnosed to have hypertension during one of her regular follow ups. She was prescribed with perindopril 8mg OD and amlodipine.

There were no other hospitalizations and no known complications from the DM and hypertension. She denies having any heart or kidney problems.

PAST SURGICAL HISTORY

Nil

DRUG HISTORY

No other drugs

ALLERGIESNo known allergies.

OBSTETRICS HX

She was pregnant 8 times. However she had 2 hx of miscarriages and 1 hx of neonatal death due to cx of DM.

FAMILY HISTORYBoth of her parents passed away. Her mother passed away because of some cx of DM. Father passed away due to old age. Siblings are all healthy.

SOCIAL HISTORYShe is married and blessed with 5 children. She is a housewife whereas her husband works as a police inspector. She does not smoke nor consume alcohol / take any illicit drugs.



DIETARY HISTORY / CULTURAL HABITSShe controls her diet. During breakfast, she usually eats 1 glass of low fat milk and half piece of whole-grain bread and fried egg. She usually skips her lunch. For dinner, she takes a lot of green vegetables fried with minimal oil and served with a scoop of rice. However, she does not do regular exercise.Upon questioning regarding foot care, she claims that she uses different footwears, denies walking barefoot, she inspects and washes feetregularly, and does proper nail clipping. However, she claims that her one of her recent footwears was fit.

PHYSICAL EXAMINATION

General conditionHeight: 1.60 mWeight: 100 kgBMI: 39.1 kg/m2 (Obese Class II)

Vital signsTemperature: 37.90CBlood pressure: 126/60 mmHg Pulse rate: 88 beats/min with regular rhythm, normal volume Respiratory rate: 18 cycles/min

Impression: Low-grade fever.

Mrs NI is a Malay lady with obese body built, lying supine on the bed supported with one pillow. She looks comfortable and not in pain, not in respiratory distress. She’s alert, conscious and oriented to time, place and person.

She is not pale and not cyanotic. Her hydration status is adequate.

Specific examination of the wound(Examination was done in supine position since the patient was unable to stand because the wound was exposed for inspection)

The affected foot (right) was compared to the left.

Inspection –

On inspection, both of the lower limbs were in normal attitude, the right foot looks swollen compared to the left. Trophic changes noted – nails and skin. No fungal infections (onychomycosis) seen. No charcot’s deformities, no prominent metatarsal head, bunions etc

The surrounding skin was dry (cracking) and hyperpigmented. (reduced hair?)

There was a single wound located at dorsum and lateral part of the right foot, extending from the lateral aspect of the base of 5th toe to 3rd toe and up to the base of the ankle, size of about 5x7cm. Depth 0.5cm. The margin was regular, the edge


Hakeema, 01/04/12,

(from outside the wound to inside)


was sloping with presence of granulation tissue, the base was pink and there was no discharge or slough or blood. The extensor tendon was exposed.

Palpation –

On palpation, the surrounding skin was warm, and non-tender. Capillary refill time was <2s.

Edema on right?

DPA was unable to palpate because of the wound but was normal in the left. PTA and popliteal were unable to appreciate

There was reduced sensation at the glove and stocking distribution of both feet (from the toes up to the distal third of the calves)

Free ROM. Limited for right due to wound

ABSI/ABPI - normal

Other systemic examinationsAll the respiratory, cardiovascular, abdominal and central nervous system examinations were unremarkable.

CLINICAL SUMMARYMrs. NI, a 42-year-old Malay lady, with a background history of uncontrolled diabetes mellitus presented with a painful ulcer at the lateral and dorsal aspect of right foot with foul-smelling discharge 4 days after undergoing wound debridement.

On physical examination, she was mildly febrile (37.9). The wound was single, rectangular shape, size of about 5x7cm, extending from the lateral aspect of the base of 5th toe to 3rd toe and up to the base of the ankle. The margin was regular, the edge was sloping with presence of granulation tissue, the extensor tendon was exposed and the base was pink and there was no discharge or slough or blood. Depth 0.5cm The surrounding skin was hyperpigmented. The DPA was unable to palpate but the PTA and popliteal were weak. Free ROM. ABSI?

PROVISIONAL DIAGNOSISInfected ulcer at the lateral and dorsal aspects of right foot

Reasons to support: History of fever History of foul-smelling discharge


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DIFFERENTIAL DIAGNOSIS1. Ischemic ulcer Pros:

PTA and popliteal were unable to palpate On examination, the wound was clean

Cons: No history of rest/night pains ABSI normal Wound debridement was done prior to the examination (no more foul-smelling discharge)

sensation over the left lower limb.

2. Wet gangrenePros:Cons: Still viable

3. NSTIPros: History of uncontrolled diabetes

Cons: NSTI extends very rapidly

3. CellulitisPros: History of uncontrolled diabetes

Cons: Involved more than the skin surface Cellulitis does not require surgical debridement

4. AbscessPros:

5. OMBone exposed?

GENERAL INVESTIGATIONSFull blood count (taken on 19th November2011) (not done during admission)

Indication: To see the WBC, to anticipate the high WBC (infective process), to monitor general condition of the patient and look at the Hb, RBC, platelet count to prepare if case she’ll need another surgical operation.WBC – 25.65 (high neutrophils)RBC – 3.94 (normal)



Hb – 10.3Platelet - Normal

Impression: High total white blood cells count might indicate an acute infection from the woundTissue cultureRBS, FBS, HbA1c

RBS – 14.3 on admissionHbA1c not done

ESR and CRPESR 13.96 (done on 24 th ) -It is necessary to get wcc and ESR?not necessary,wcc is enough to check for inflammation but ESR can be used to monitor the progression of patient condition regarding the infection-what is ESR? How ESR was done in lab? Normal values for ESR and the unit>20mm/hours-then, what is CR-P?different with ESR

Urea & Electrolytes (taken on admission)Indication: To assess renal function of the patient.

Test Result Unit Normal range ImpressionUrea 3.6 mmol/L 1.7-8.3 Normal

Sodium 141 mmol/L 120-160 NormalPotassium 3.5 mmol/L 3.5-6.5 NormalCreatinine 80 umol/L 44-88 Normal

Impression: No siginificant abnormality.

Tissue culture (after WD) –P.aeruginosa (came back on 16th)XRay done on admission – normal no OM changes

FINAL DIAGNOSISInfected secondary to MANAGEMENTIn the emergency department1. Vital signs monitoring.2. WD3. Daily dressing, elevate R LL

In the ward upon admissionSpecial dressing – demacele with saline waterSurgical or amputationAntibiotic – IV 1.5g TDSunasyn sulbactam and ampicillinAnalgesic IM tramal 50mg TDSSc insulin R1 18u TDSSc insulin NI 26u ON


Hakeema, 12/12/11,


ABSIPROGRESS OF PATIENT16 th

- FBG 8.4 on sliding scale18th November 2011Amputated of right 5th toe. Wet gangrene. Slough ++, no pus

19th Culture – mixed growth. 20th NovemberPus expressed when inspectedWBC 25.15Culture –ve and +veXR tro Om changes eg periosteal changes and lytic lesion (late)HBa1c?25th November 2011DischargedRefer to podiatryDISCHARGE SUMMARYUpon discharge, the patient is stable, well and comfortable. Currently she is afebrile, Day 6 after right 5th toe amputation and repeated WD

DISCUSSION Mrs NI is a middle-aged lady presented with a background history of

uncontrolled diabetes mellitus. She had a history of foot ulcer which was debrided and 4 days later, she presented again to the ED due to poor healing wound. According to National Health and Morbidity Survey 1996, foot ulceration associated with infection is one of the leading causes of hospitalization patients with diabetes mellitus. Approximately 15% of all patients with diabetes will develop a foot or leg ulceration at some time during the course of their disease. Several population-based studies report an annual incidence of diabetic foot ulceration in the range of 2% to 3% in patients with either Type 1 or Type 2 diabetes, while the prevalence varies between 4% and 10%. Numerous risk factors for diabetic foot ulceration have been ascertained. Mrs NI – obese class II, most probably the reason why sugar is poorly controlled despite compliant to OHAs

However, it is known that there are 3 factors which play a role in its pathogenesis


Hakeema, 12/12/11,

HbA1c/FBG/RBG. Ix – HbA1c Glycosylated hemoglobin level must be taken to obtain information of the patient’s glucose control over the past 3 months. This investigation is based on the fact that in the normal 120 day life span of the red blood cell, excess glucose molecules will react with hemoglobin, forming glycosylated hemoglobin. In individuals with poorly controlled diabetes, the level of glycosylated hemoglobins will be elevated. Plain radiograph of foot and ankle can also be taken to make sure there is no involvement of bone to rule out osteomyelitis.


In the peripheral neuropathy complication of DM, patient will have abnormal sensory, motor and autonomic symptoms. Whereas in peripheral vasculopathy, it is due to the atherosclerosis at the medium-sized arteries which include the popliteal artery, DPA, and PTA. And also immunopathy.



Usually, an ulcer can be differentiated whether it is neuropathic vs ischemic ulcerFeatures

Ischaemic foot

• There is a history of intermittent claudication.

Neuropathic foot

Hx of pins and needles

Nature of foot

• On examination indications of peripheral vascular disease (skin is cool, pale or cyanosed, shiny and thin, with loss of hair, and onychodystrophy; peripheral pulses are absent or weak; the ankle brachial index is <0.9) are present. Ulcer – redness at the border, pale /yellowish/black(necrotic) base, minimal granulation tissue (poor healing)• Non-invasive vascular testing (duplex or triplex ultrasound examination, segmental pressures measurement, plethysmography), and angiography confirmperipheral vascular disease.There are no findings of peripheral neuropathy (sensitive to sensation)

• On examination evidence of peripheral neuropathy (hypoesthesia or complete loss of sensation of light touch, pain, temperature, and vibration, absence of Achilles tendon reflexes, abnormal vibration perception threshold, often above 25 V, loss of sensation in response to 5.07 monofilaments, atrophy of the small muscles of the feet, dry skin and distended dorsal foot veins) is present. However, the pattern of sensory loss may vary considerably from patient to patient. The foot has normal temperature or may be warm. callus formation at the borders of the ulcer. • Its base is red, with a healthy granular appearance. • Peripheral pulses are present and the ankle brachial pressure index is normal or above 1.3. (base of metatarsals/pressure points), better healing with granulation tissue, pulse present

Pain Painful Painless

Foot pulses

Absent Palpable

Site of ulcer

Sides of digits (peripheries)Rest pain • Develop on the borders or the dorsal aspectof the feet and toes or between toes.

Plantar surfacePressure points peripheries high plantar pressures(metatarsal heads, plantar aspect of the great toe, heel or over bony prominences

Complications

Ulceration/NecrosisGangrene

Charcot's joint (not evident in this patient)



In this case Mrs NI presented with a history of skin dryness (autonomic symptom) and pins and needles at the stocking distribution of both feet (peripheral sensory neuropathy) for one year, which correspond with the physical examination. She also has peripheral vasculopathy as the PTA and popliteal artery were weak and this was evidenced by the ABSI which was ___________.Neuro-ischemic ulcers have a mixed etiology, i.e. neuropathy and ischemia, and a mixed appearance.

Another classification which King’s / Wagner’s Classification of Diabetic Foot Ulcers81Grading

Stage description

I Stage 1: Normal Diabetic alone 0Pre-ulcer. No open lesion. May have deformities, erythematous areas of pressure or hyperkeratosis.

II Stage 2: High Risk Diabetic + neuropathy or ischaemia 1Superficial ulcer. Disruption of skin without penetration of subcutaneous fat layer.

III Stage 3: Ulcerated Diabetic + ulcer but no infection2Full thickness ulcer. Penetrates through fat to tendon or joint capsule without deep abscess or osteomyelitis.

IV Stage 4: Cellulitic Stage

Diabetic + infection (cellulitis) 3Deep ulcer with abscess, osteomyelitis or joint sepsis. It includes deep plantar space infections, abscesses, necrotizing fascitis and tendon sheath infections.

V Stage 5: Necrotic Diabetic + necrotic tissue Features 4Gangrene of a geographical portion of the foot such as toes, forefoot or heel.

VI Stage 6: Major Amputation

Major amputation5Gangrene or necrosis of large portion of the foot requiring major limb amputation.

IX- XRayI would like to order for fasting lipid profile. Prolly she requires anti cholesterolemiaI would like to do FBC on the day of admission~upon admission, King’s Stage 3, but after investigations, King’s Stage 5 – amputation to prevent further extension or spread of the infection


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ABSI ABSI if chronic (<0.6), CT angiogram to see the level of blockage, mx: refer to vascular surgeon


Debridement is the removal of all non-viable tissues and slough from theulcer. It is only after a thorough wound debridement that application of topicalwound healing agents, dressings or wound closure procedures are carriedout 40, 86, 87, 88.

a.Surgical debridement is an important and effective procedure in themanagement of diabetic foot ulcers 88. This involves surgical debridementand removal of all nonviable tissue / bone until healthy bleeding soft tissue/ bone are encountered. Diabetic foot abscesses requires immediate incisionand drainage. Osteomyelitic bones, joint infection or gangrene digits requireresection or partial amputation 41, 89, 90, 91. Regular and repeated debridementof necrotic tissue leads to early closure of the diabetic ulcer 88, 92.

b.Mechanical debridement includes surgical debridement, wet-to-drydressings and high- pressure irrigation 17, 40, 60, 93, 94.

c.Enzymatic debridement uses topical proteolytic enzymes as adjuvant inmanaging chronic wounds. Their efficacy is however controversial 40, 60, 93.

d. Autolytic debridement occurs naturally in healthy, moist wound environmentwith adequate circulation 7.

Normal saline dressingsDischarged when -



According to a London journal abt Managing Diabetic foot, the most important thing is the prevention which mainly involves self-Care at Home. A person with diabetes should do the following:

Foot examination: Examine your feet daily and also after any trauma, no matter how minor, to your feet. Report any abnormalities to your physician. Use a water-based moisturizer every day (but not between your toes) to prevent dry skin and cracking. Wear cotton or wool socks. Avoid elastic socks and hosiery because they may impair circulation.

Eliminate obstacles: Move or remove any items you are likely to trip over or bump your feet on. Keep clutter on the floor picked up. Light the pathways used at night - indoors and outdoors.

Toenail trimming: Always cut your nails with a safety clipper, never a scissors. Cut them straight across and leave plenty of room out from the nailbed or quick. If you have difficulty with your vision or using your hands, let your doctor do it for you or train a family member how to do it safely.

Footwear: Wear sturdy, comfortable shoes whenever feasible to protect your feet. To be sure your shoes fit properly, see a podiatrist (foot doctor) for fitting recommendations or shop at shoe stores specializing in fitting people with diabetes. Your endocrinologist (diabetes specialist) can provide you with a refferel to a podiatrist ororthopedist who may also be an excellent resource for finding local shoe stores. If you have flat feet, bunions, or hammertoes, you may need prescription shoes or shoe inserts.

Exercise: Regular exercise will improve bone and joint health in your feet and legs, improve circulation to your legs, and will also help to stabilize your blood sugar levels. Consult your physician prior to beginning any exercise program.

Diabetes control: Following a reasonable diet, taking your medications, checking your blood sugar regularly, exercising regularly, and maintaining good communication with your physician are essential in keeping your diabetes under control. Consistent long-term blood sugar control to near normal levels can greatly lower the risk of damage to your nerves, kidneys, eyes, and blood vessels.

Medical Treatment

Antibiotics: If the doctor determines that a wound or ulcer on the patient’s feet or legs is infected, or if the wound has high a risk of becoming infected, such as a cat bite, antibiotics will be prescribed to treat the infection or the potential infection. It is very important that the patient take the entire course of antibiotics as prescribed. Generally, the patient should see some improvement in the wound in two to three days and may see improvement the first day. For limb-threatening or life-threatening infections, the patient will be admitted to the hospital and given IV antibiotics. Less serious infections may be treated with pills as an outpatient The doctor may give a single dose of antibiotics as a shot or IV dose prior to starting pills in the clinic or emergency department.



Referral to wound care center: Many of the larger community hospitals now have wound care centers specializing in the treatment of diabetic lower extremity wounds and ulcers along with other difficult-to-treat wounds. In these multidisciplinary centers, professionals of many specialties including doctors, nurses, and therapists work with the patient and their doctor in developing a treatment plan for the wound or leg ulcer. Treatment plans may include surgical debridement of the wound, improvement of circulation through surgery or therapy, special dressings, and antibiotics. The plan may include a combination of treatments.

Referral to podiatrist or orthopedic surgeon: If the patient has bone-related problems, toenail problems,corn and callus hammertoes, bunions, flat feet, heel spurs, arthritis, or have difficulty with finding shoes that fit, a physician may refer you to one of these specialists. They create shoe inserts, prescribe shoes, remove calluses and have expertise in surgical solutions for bone problems. They can also be an excellent resource for how to care for the patient’s feet routinely.

Home health care: The patient’s doctor may prescribe a home health nurse or aide to help with wound care and dressings, monitor blood sugar, and help the patient take antibiotics and other medications properly during the healing period.

The principles of dressing a healing wound include keeping it moist, managing exudates using appropriate dressings, and protecting the surrounding intact skin.15 When starting antibiotics, the most appropriate route, spectrum of activity, and duration of treatment should be considered, according to local policy. If the patient has systemic signs of infection, intravenous antibiotics are needed.

REFERENCESNHMS5. Edmonds ME and Foster AVM. Managing the diabetic foot, 2nd ed. (Blackwell, London, 2005).National Institute for Health and Clinical Excellence (www.nice.org.uk/nicemedia/pdf/CG010NICEguideline.pdf)—UK guidelines on management of foot problems in patients with diabetesDFU 2006Atlas of DF

NAME OF STUDENT: HakimahDATE: COMMENTS:

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GRADE:



NAME OF SUPERVISOR: Dr. Yohan A Khirusman


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