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Post by robertisaacs on Sept 7, 2008 13:38:30 GMT
Another Challenge for y'all. This one limped into my clinic couple of weeks ago.
Patient presents with a 6 month history of ulceration on his right 5th toe, WB lateral apical area. Becoming worse (larger, deeper, more painful. Circulation is dire with toes blue shading to black in places and monophasic DP pulses. Patient had polio and the affected leg (right) is around 2 inches shorter. Can make 90 degrees but is very, very stiff and generally in equino varus.
The patient has surgical shoes made at the surgical appliance lab with the heel raise built in and a soft cavity under the 5th toe. However on presentation the patient reports that the foot has now become swollen to the point that the patient can no longer get these shoes on. Since then he has been wearing moccasin slippers (all he can wear) and has developed a new ulceration RA3 (another blue black toe).
On examination of the ulcer there is a necrotic area in the center. Excruciatingly painful to irrigate much less debride.
On gait the right foot contacts lateral digits / forefoot first then medial forefoot and finally heel as the pt loads the limb. Heavy, heavy limp off the shorter leg. Obviously painful.
The Surgical appliance lab has a 2 week wait to see them and anywhere up to 3 months to actually get anything so no help likely to be forthcoming there.
With access only to an insole manufacture lab with only the usual equipment and materials, what do you do?
Happy Mulling
Robert
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Post by Admin on Sept 7, 2008 19:57:36 GMT
Hi Robert,
Not quite the answer you're looking for, but I would refer via the GP to the Vascular Surgeon as a matter or priority.
DP Doppler readings are useful, but only as an indicator.
Monophasic bruit and blue toes suggest to me that orthoses are not necessarily the best way to go, especially when faced with longish waiting times from the appliance people.
Cheers,
David
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Post by robertisaacs on Sept 7, 2008 20:12:04 GMT
LOL
Great minds think alike! That was exactly what the diab lead did!
Vascular team saw him post haste but said there were no blockages. Bounced him back to us.
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Post by davidsmith on Sept 7, 2008 20:31:48 GMT
Robert
David's excellent suggestion notwithstanding, if your intention is to reduce plantar pressure - How about a walking stick used in the opposite hand and supporting bodyweight during ipsilateral swing phase. - Or crutches for complete non weightbearing ambulation. On the other hand does walking promote increased circulation due to leg pump action. Therefore complete non w/b might be contra indicated. Perhaps sitting exercises to activate the GSC might help increase circulation when it might otherwise be sluggish or pooling.
A rocker shoe is shown in many studies to reduce forefoot pressure and pathology due to excessive forefoot pressure. Might it be a good idea to make an insole that allows longer mid foot weight bearing during the stance phase of gait?? (difficult perhaps with an equinus ankle and lld.) Perhaps he has a valgus forefoot or some other function that forces lateral CoP at propulsive stage. Is the STJ or mid foot mobile enough to make an orthosis that promotes a medial shift of the CoP at propulsive stage? Perhaps he has a FncHL and this forces the compensation of a lateral shift of the CoP the usual FncHL mods may reduce this tendency.
Just some suggestions to mull over.
Cheers Dave Smith
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Post by davidsmith on Sept 7, 2008 20:54:32 GMT
Robert
You replied to David H
Was there any significant artherosclerosis?
In which case considering your description and discounting kidney and heart disease since you don't mention them, it sounds as if your patient has venous insufficiency and venous stasis ulceration, would the prescription of toeless support hose be worth while?
Dave S
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Post by twirly on Sept 8, 2008 5:36:26 GMT
My thoughts: If ischeamia & / or venous insufficiency were evident I would not debride unless the patient was also attending other support clinics eg. vascular dressing team. If by debriding an already ischeamic wound there is always the possibility of causing further non-healing areas.
As this pt. has been bounced back to Pod' I would write to the GP/Consultant expressing my concerns & advise the pt. to become non-weight bearing until further vascular assessment or appropriate footwear could be obtained.
In the mean time I also like David Smiths suggestion of a walking stick to alleviate pressure when w/b is absolutley necessary.
Possibly not suitable but only a suggestion until the orthotics lab can provide his boots/shoes: What about velcro type slippers with extra depth to accomodate cushioning in at risk areas?
Just my thoughts.
Mand'
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Post by robertisaacs on Sept 8, 2008 7:12:06 GMT
Insert french accent here.
"well i ask him but i don't think he'll be very keen. He's already got one you see?"
A better idea, however i'm not sure that given the degree of equino varus he'd manage that without scraping the toes on the ground. Also, not a young man, i'm not sure he'd have the upper body strength for it!
Interesting ideas Insole wise, again not really do able due to the degree of EV. Irrespective of what the foot is doing in the shoe, the shoe itself is whats hitting the ground lateral forefoot - medial forefoot - rearfoot.
Was there any significant artherosclerosis?
Possibly. Does not address the mechanical component though. I suspect given the gait he migh ulcerate even if he had decent circulation!
I think Twirls' answer shows excellant though processing! Some nice out of the box thinking as well.
Probably wise. I only had to do it once. I leave the gooey dressing stuff to them as likes it!
Taking the patient off their feet altogether is certainly a route to consider although not one the patient would probably comply with.
Now you're talking! Expand and develop!
Karma for twirly
Regards
Robert
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Post by dtt on Sept 8, 2008 19:39:07 GMT
Ok Here goes my thoughts 3 x 7mm felt base on short leg with met raise/ rocker in felt with accomodation of any plantar lesions. Stop felt proximal to digits to "float them" to offload digits. Similar on the long leg but to balance pt all in a cast slipper or aircast boot. Bounce it back to anybody but you   Hope that helps Cheers D  |
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Post by robertisaacs on Sept 9, 2008 7:44:41 GMT
This from the man who claims not to be 100% on biomechanics . That is exactly what i would do in a clinic. With the benefit of a lab i did the following. Got the patient to go buy a pair of cheap velcro 3 strap sandles. Marked sulcus length on the foot. Put affected foot in sandle so marks transfer. Cut the sandle off at sulcus level. Cut a step into the distil end and replaced sandle lining with PPT so that the distil edge did not aggravate. Grind off the patterned bit of the sole (of the sandle obviously :  Stick a 40mm Black EVA block to the base of the sandle. Grind the block so that it has a rocker in the sagital plane and a lateral flare to controll the inversion (about 25mm lateral expansion). Glue a sole to the base so it does not wear out too fast. Cheap pair sandles £10 Block of EVA, around £7 Hard wearing impact sole £2 PPT to prevent leading edge trauma £0.25 Having the patient with the lld compensated, lateral stability and precisely no pressure on the lesions, Priceless. There are some things money can't buy. For everything else, there's the lab stock budget. There is a point to this. Somebody on TFS recently argued that biomechanics and in shoe functional  Orthotics are one and the same thing. The truth, IMO, is that everything we do is shot through with biomechanics and it is useful to free one's mind from the Patient comes with pathology, gets insole mindset. Biomechanics is simply the application of mechanical principles to patient care. Dave's walking stick was biomechanics. Mandy's footwear change was biomechanics. Del's felt was biomechanics. Martins Dermal fillers are biomechanics I think it is well to remember that. Contrary to popular belief there are few pods who ""never do biomechanics" Thanks all for playing. Karma for del. Regards Robert |
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Post by dtt on Sept 9, 2008 18:52:04 GMT
Hi Rob Just to say thank you for sharing you knowledge with me / us at the Tamworth's ( and the rest of you that did presentations) to change my mindset into an "out of the box" thought process I look forward to your podopaediatric day for the same reasons Thank you my friend, an honour coming from you Cheers M8 D |
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Post by lawrencebevan on Sept 11, 2008 16:14:31 GMT
sorry to be pedestrian
what glue do you use for this kind of footwear modification??
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Post by dtt on Sept 11, 2008 17:29:50 GMT
Hi Lawrence Don't be. ;D ;D The effect of comments here transfer well to other sites  Cheers Derek |
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Post by davidsmith on Sept 11, 2008 17:52:57 GMT
Lawrence
"what glue do you use for this kind of footwear modification?? "
The Strong kind !
LoL Dave
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Post by robertisaacs on Sept 11, 2008 19:05:27 GMT
my usual lab glue is renia ortec. Strong, easy to use and safe. However for this style of thing I use gripsotite neophrene cement which is vicious nasty stuff which you can't use if pregnant or if you don't want nosebleeds
Proper clamping is also required.
Regards
Robert
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Post by dtt on Sept 11, 2008 19:09:28 GMT
Dave I am having a problem with top covers detaching on my O's from my lab. "Gimme a clue please on the glue" A rapper I will be !! ;D ;D Sorry Can you or anyone help ?? Thanks D |
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Beautiful people are inside out.
Orthotics are one and the same thing. 