Archive for December, 2009

Preventing Diabetic Foot Complications

December 28, 2009


Foot amputation is one of the most serious complications that diabetics may encounter.  Fortunately, diabetics do not have to bear the burden of keeping their feet healthy alone. Not all amputations associated with diabetes can be avoided, but with routine foot examinations by a podiatrist and daily self-examination of the feet by the patient, diabetic foot complications may be prevented. In order to thwart these complications, an understanding of how and why these problems occur must be recognized.

Understanding Diabetic Foot Complications:
Diabetes causes an increase of sugar levels in the blood, which causes a process of “glycosylation” to be increased. Glycosylation is a normal process in the body that attaches chains of molecules to protein found in nerves, tendons, and cartilage.  Increased glycosylation, over time, begins to damage the function of these structures.

A vital function of nerves is the ability to convey pain, which allows us to recognize problems with our body. Due to the importance of pain as our body’s fire alarm, damaged nerves become a major risk factor for formation of diabetic foot wounds. Increased glycosylation of nerves leads to decreased pain sensation and therefore results in the loss of protective sensation. This situation becomes detrimental to diabetics, who are now unaware of small lacerations, wounds or callus on their feet that might lead to more serious complications such as ulcers and bone infections. If wounds are left untreated, they may result in amputation.

In addition to increased sugar levels, diabetics also tend to have high lipid concentrations in the blood. This produces the build up of plaque in the arteries, which results in poor circulation to tissues. Tissues depend on blood circulation for nutrients and oxygen to stay healthy and fight infections. Consequently, circulatory problems may not directly lead to ulcers on the feet, but exacerbates diabetic foot complications by creating a poor environment for wounds to heal.

The Role of the Podiatrist in Diabetic Foot Care:
Podiatric diabetic foot examinations are used to assess the risk of diabetic wounds and usually follow a methodical procedure that examines the entire foot from joint mobility and skin condition to nerve and vascular function.

Vascular Exam:
In a routine diabetic foot exam, circulation is determined by feeling for pulses in the feet. If pulses are not felt or are weak, then an ultrasound Doppler test may be used to listen and record the status of the pulses. If the Doppler test indicates poor circulation, the podiatrist may refer the patient to a vascular physician in order to treat the patient to enhance the blood circulation to the feet. The podiatrist may also observe any swelling, skin color changes, and cold temperature in the feet, as this may indicate poor circulation as well.

Neurological Exam:
In a neurological exam of the foot, the loss of protective sensation is assessed by using an instrument called a Semmes-Weinstein Monofilament, which is made out of a thin plastic wire. While the podiatrist touches the patient’s feet with the monofilament wire, the patient closes his or her eyes and tells the doctor whether or not they feel the instrument. An inability to feel the wire indicates that the patient cannot appropriately protect himself or herself from injury. These injuries can be cuts, callus or foreign body. It is important to note that neglecting the discovery of any of these injuries even for a single day can lead to an ulcer and later, an amputation.

Skin Exam:
During the skin exam, calluses, cracking, and nail conditions are noted and evaluated. Thick nails may result in painful ingrown nails or pressure soars that can harbor bacteria and lead to infections in the foot. . The condition of the skin is examined as well to ensure that there is no fungal growth, foreign bodies, and excessive moisture or dryness that promotes bacteria growth and skin deterioration.

Muscular Exam:
In order to prevent excessive pressure on the feet, bony prominences will be identified. The range of motion of joints is assessed by measuring joint motion with a tractograph. If there are painful bony prominences and decrease joint mobility, specialized diabetic shoes may be needed to provide extra depth for the feet and decrease friction against the skin. The combination of increased pressure and loss of protective sensation increases the risk of ulcers in diabetic patients. Additionally, muscle strength is evaluated in order to determine the stability of the foot. If muscle strength is found to be weak, bracing may be recommended to provide support.

The Role of the Diabetic Patient and Family Members in Diabetic Foot Care:
The responsibility of the diabetic patient and family members in preventing diabetic foot complications is just as important as the roles of the podiatrist. Here are tips to take care of diabetic feet:

1. Since diabetics are at risk of losing sensation in their feet, it is imperative that self-inspection of the feet is performed every day. If it is difficult to bend the knees to see the bottom of the foot, a magnifying mirror can be used. The mirror can be placed on the ground, while the patient looks to find any sores or foreign objects in the feet. If there are family members to assist the patient, they can inspect the feet for any wounds as well. If lesions are noted, the patient should see a podiatrist promptly to ensure timely and proper treatment of the wound.

2. Routine podiatric visits are important in maintaining diabetic foot health, especially since during these visits, calluses and nails can be debrided to relieve any excessive pressure to the feet. Furthermore, routine visits can provide early warning signals of impending problems, as detailed in this article.

3. Diet and blood sugar level should be controlled to decrease the progression of loss of protective sensation in the feet.

4. Daily foot hygiene should be incorporated into diabetic foot care. This includes washing the feet and changing socks daily. Making sure that the foot has adequate moisture, which can be ensured by moisturizing lotion. Be careful with over-moisturized feet for this may lead to the breakdown of skin.

5. Ensure that shoes fit comfortably to avoid pressure to the feet. When buying shoes, a wide toe box is advised.

6. Avoid walking barefoot to prevent stepping on foreign objects.

8. Be cautious when taking baths or going to steam rooms because with decreased sensation, the chances of getting burns increases. When taking baths, test the water first with a thermometer or your hand.

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Surgery: Post op instruction

December 26, 2009

I am displaying the following post-operative instructions for the use of patients that I have operated on.  Depending on the type of surgery, and findings noted during the surgery, you may have been given special orders other than the ones listed on the page.  If that is the case, those orders would have been written on the instruction form in the area marked additional instructions.

As far as the post-operative medications are concerned, if you have a history of stomach or bleeding problems or allergies you may have been given medications other than the ones listed on this instruction page.

Finally, with regard to the section on when to call the office. It is very important to both the doctor and the patient that we keep in touch after the surgery.  If you have any questions about what you should be doing or if you are not sure about what to expect, please call the office.

BRUCE LASHLEY, D.P.M.

353 LEXINGTON AVENUE, SUITE 1501

NEW YORK, NY 10016

(212) 949-2901

http://www.footdoctornyc.com

POST-OPERATIVE INSTRUCTIONS

___Elevate your foot above the level of your heart as much as possible the first week

___Use ice around the ankle for about 15 minutes 4-6 times a day

___Rest in bed with the foot elevated the first two days

___After the second day minimal walking until your follow up visit

___Walk at all times with the post-op shoe or the Boot walker and use the cane

___Keep bandage clean and dry. Do not wet or change the bandage.

___Additional instruction___________________________________________________

________________________________________________________________________

MEDICATIONS:

___Ansaid—one tablet two times per day. This should be taken with food.

This medication is for mild pain and to help keep the swelling down.

___Tylenol with Codeine #3—one or two tablets every four to six hours as needed for

pain. This medication is for pain.

NEXT APPOINTMENT

Your follow-up appointment will be with Dr Lashley at his office on: M  T  W  TH  F

____/____/20____

CALL THE OFFICE IF:

  • You have severe pain that is not controlled with the medication.

  • You have blood soaking through the bandage.

  • Your bandage gets wet.

  • Your foot stays numb on the second day following the surgery.

  • You have any questions regarding the surgery or the postoperative instructions.

Patient understands Sign here___________________________________________

BRUCE LASHLEY, D.P.M.________________________ DATE: ___/___/______

Amerigel instructions after nail surgery

December 12, 2009

GENERAL INFORMATION:

Stay off your feet as much as possible today. You may
wear any shoe, sandal or open toe footwear that does
not squeeze, constrict or put pressure on your toe(s).
Your toe(s) may remain numb for up to 6-10 hours after
the procedure. Please contact our office if you have any
questions or concerns.

Bleeding: Slight bleeding, discoloration and drainage
are normal.

Discomfort: You can elevate your foot to help
alleviate minor swelling, bleeding and discomfort.
You may also take Aspirin, Tylenol or other over-the counter
pain relievers as directed on the package. If
pain or discomfort is not controlled adequately, then
contact our office.

Removing the surgical bandage: Starting the
second day after surgery, carefully remove the dressing
and shower or bathe as normal. If the gauze or bandage
sticks to the area, dampen it with water or shower/bathe
with the bandage in place. This will make it easier to
remove with minimal or no discomfort.

DRESSING SHOULD BE CHANGED ONCE DAILY

FOLLOWING BATHING.

Instructions following
Nail Surgery using AMERIGEL®
WOUND DRESSING

Step 1: After showering or bathing, blot the
surgical site (nail bed) dry and apply a liberal
amount of AmeriGel Wound Dressing. Stinging
may occur and is normal.

Step 2: Cut a suitable size piece of gauze to fit
directly over the entire surgical area.

Step 3: Secure gauze in place with a band-aid.
IMPORTANT: The band-aid should be applied
around the toe resembling a ring. When dressing
a toe, apply band-aid loosely.

Why should I have a skin biopsy?

December 6, 2009

Why should I have a skin biopsy?

Skin cancer. How do you know if you have it? Ever wonder about that spot on your foot? Is it new? Has it changed? Does it bleed? Is it darker then it was in the past?

Growths (lesions) or discolorations of the skin occur all over the body, including the feet. So, it is not surprising when your podiatrist requests that you should have a biopsy to further determine the exact nature of the lesion on your foot. Often, more serious life-threatening skin conditions that appear on the feet are assumed to be warts, calluses or blisters. Unless these skin lesions are biopsied and sent to a skin pathologist for examination under a microscope, there is a good chance that the true diagnosis will be missed. The biopsy will determine the exact nature and true diagnosis of the skin problem, and will find if the lesion is malignant or benign.

There are several types of skin biopsies that can be performed by your podiatrist in the office. They are called: Punch, Shave and Excisional biopsies. The method performed depends on the location of the problem area and the type of skin lesion that is being investigated. Most of the time, the biopsy is done to remove a small portion of the skin in order to send a specimen to the lab for special staining and subsequent examination under the microscope.

Things to expect when you have a skin biopsy:

Most skin biopsies are performed in the office. After the injection of local anesthetic, the procedure itself should not be painful. Once the area is numbed by the anesthesia the skin is cleansed to avoid infection. Next, the doctor will use a surgical instrument to remove all or part of the skin lesion. A blade is used for Shave or Excisional biopsies and a cylindrical cookie-cutter type of instrument is used for the Punch biopsy. After the skin sample is taken, an anti-bleeding solution is applied. In rare occasions, one or two stitches may be needed to close the wound. The doctor then will apply a bandage over the wound.

The bandage is left in place until the next day when routine wound care can be started at home. There is very little post-procedure pain from these biopsies and patients may have to take Tylenol when the anesthesia wears off.

Now it is about two weeks since you had the biopsy and it is time to return to the doctor’s office for a wound check and, most importantly, find out the result of your biopsy. Most often, the final diagnosis from the biopsy taken in the office will take around seven to ten days to get back to the doctor. The doctor will go over your results from the report that he received from the lab and review the treatment for your condition. I suggest that all patients take a copy of the lab report for their personal records. Now you have your answer, hope the news was good.

Other reasons for having a biopsy:

Have you had redness and itching on your feet? Do you have coin size patches on your feet? Do you have skin lesions with small dark spots? Have you used over the counter fungal creams and not seen improvement? Do you have an area on your foot that is drier, scalier, thicker or darker than your normal skin?

  • To determine the cause of the skin problem. Biopsy can let the doctor know if the skin problem is being caused by an infection, such as fungus, verses an inflammatory condition like dermatitis. Also referring to the case above, to determine if the condition is a cancerous verses a benign growth.
  • To accurately form the best course of treatment for the skin condition. If the result of the test shows there are no fungal elements, then anti-fungal agents would be useless in treating this condition. Also, if the result shows that the skin problem is from a fungus, using anti-bacterial such as polysorin or anti-inflammatory agents like steroid creams would be useless The result of the study may also suggest that the entire lesion be removed because this condition may have a chance of turning into a cancerous condition in the future.
  • Biopsies can determine if the hard strange skin on your foot is a callus or a plantar wart. Knowing this can help appropriately treat the condition.