The 4 C’s about Ulcerations: Causes, Concerns, Conditions, and Care.

Dr. Ned M. Ramadan, DPM

228 New Haven Avenue

Milford, CT 06460

Ph: (203)701-0252

Fax: (203)876-0937

Lower extremity ulcerations overview.

Foot and lower leg open sores known as ulcerations.

The 4 C’s you need to know: Causes, concerns, conditions and care.

Prevention and various treatments.

Open sores known  as ulcerations on the foot and lower leg are limb and life threatening conditions requiring immediate medical attention and care.

Ulcerations vary in dimensions and locations along the entire body including the buttocks, lower leg and foot.

Ulcerations require immediate medical attention and avoiding self diagnosing and treatment due to its limb and life threatening condition.

Recognition followed by a thorough understanding and immediate care is crucial to a successful outcome.  Furthermore, it is essential that a medical team approach is adopted to optimize the care.

It is important to recognize and acknowledge the ulceration by either self observation and or others followed by immediate medical care.  The medical professional will then educate you regarding the cause, short and long term treatment goals, and prevention options.

The relevance of advanced studies of the lower extremity circulatory status are vast and important regarding the outcome of the ulceration.

The benefits of various prescription medications, over all healthy living through sound diet, exercise and stress free life style, early detection followed by multi medical professional care is essential to the outcome and prevention.

In depth discussion regarding the various synthetic to biological dressing changes to skin and soft tissue debridement, skin grafting and local tissue flap closures.

Importance of proper local wound care, home nursing, offloading, medication, and diet in lower extremity ulcerations on either foot and or leg.

Please join us for an educational presentation regarding ulcerations of the foot and lower leg.

ULCERATION IS THE MEDICAL TERM FOR OPEN WOUND.

ULCERATIONS ARE BREAK DOWN IN THE PROTECTIVE LAYER OF EITHER SKIN AND OR INTERNAL LINING SUCH AS THE GASTRO-INTESTINAL TRACT.

CAUSES:

  • HEREDITARY,
  • IRRITATION DUE TO REPETITIVE FORCE AND PRESSURE,
  • MECHANICAL INSTABILITY (DIRECTLY AND OR INDIRECTLY),
  • POOR CIRCULATION (ARTERIAL AND VENOUS),
  • MEDICAL CONDITIONS SUCH AS CONGESTIVE HEART FAILURE, RENAL (KIDNEY) DISORDERES, DIABETES AND OTHERS.
  • AGE DUE TO FAT ATROPHY (DIMINISHMENT) AND ARTHRITIS SETTING CAUSING DEFORMITY AND ENLARGEMENT OF JOINTS AND BONES INTURN CAUSING PRESSURE AND ABNORMAL FORCE,
  • MEDICATIONS AND METABOLISM
  • ALLERGIC REACTIONS
  • DIET
  • NEOPLASMS (BENIGN AND MALIGNANT).

LOCATIONS:

ENITRE BODY PARTS; MOST COMMONLY THE BUTTOCKS, LEGS AND FEET.

TYPES OF WOUNDS:

DRY, MOIST AND WEEPING (DRAIN A LOT) WOUNDS, NECROTIC AND GANGRENOUS.

DIMENSIONS:

  • IRRITATION WITH REDNESS NO BLISTERING EFFECT
  • PARTIAL THICKNESS OF THE SKIN INVOLVING THE EPIDERMIS  (OUTER PROTECTIVE LAYER OF THE SKIN);
  • FULL THICKNESS OF THE SKIN INVOLVING THE EPIDERMIS AND DERMIS (LAYER BENEATH THE EPIDERMIS);
  • SUB CUTANEOUS (FAT LAYER);
  • FASCIAL LAYER (FIBEROUS LAYER OVER THE MUSCLES TYPICALLY AND UNDERNEATH THE FAT LAYER);
  • MUSCLE LAYER,
  • IN THE PODIATRIC MEDICAL FIELD, WE TYPICALLY FOLLOW WAGNER’S CLASSIFICATION:

Grade 0 – skin with prior healed ulcer scars, areas of pressure which are sometimes called pre-ulcerative lesion or the presence of bony deformity which puts pressure on an unguarded point.

Grade I – A the wound is superficial in nature, with partial or full thickness skin involvement but does not include tendon, capsule or bone.

Grade I – B as above, the wound I superficial in nature, with partial or full thickness skin involvement but does not include tendon, capsule nor bone; however, the wound is infected. The definition of this wound implies superficial infection without involvement of underlying structures. If the wound shows signs of significant purulence or fluctuance, further exploration to expose a higher grade classification of infection is in order.

Grade I – C as above but with vascular compromise

Grade I – D as above but with ischemia. Because ischemia is a type of vascular compromise, the distinction between these two grades is often difficult to make.

Grade 2-A penetration through the subcutaneous tissue exposing tendon or ligament, but not bone.

Grade 2-B penetration through the deep tissues including tendon or ligament and even joint capsule but not bone.

Grade 2-C as above 2B, but including ischemia.

Grade 2-D as above 2C, but including infection.

Grade 3-A a wound which probes to bone but shows no signs of local infection nor systemic infection.

Grade 3-B a wound which probes to bone is infected.

Grade 3-C a wound which probes to bone is infected and is ischemic.

Grade 3-D a wound which probes to bone characterized by active infection, ischemic tissues and exposed bone.

Grade 4 gangrene of the forefoot

Grade 5 gangrene of the entire foot. 

CONCERNS:

OPEN WOUNDS REQUIRE IMMEDIATE MEDICAL ATTENTION AFTER PATIENT RECOGNITION.

OPEN WOUNDS COULD LEAD TO LIMB AND LIFE THREATENING CONDITIONS IF NOT PROPERLY TREATED.

OPEN WOUNDS OFTEN GET INFECTED REQUIRING ORAL VS INTRA VENOUS ANTIBIOTICS.

OPEN WOUNDS CAN LEAD TO AMPUTATIONS.

CHECK YOUR FEET AND LEGS DAILY; OTHERWISE, HAVE YOUR SPOUSE AND OR FRIEND CHECK.

DO NOT SELF DIAGNOSE AND TREAT YOURSELF.

DO NOT ASK YOUR NEIGHBOR OR FRIEND WHAT THEY HAD AND HOW IT HEALED.

EACH INDIVIDUAL CASE IS DIFFERENT.

TREATMENTS:

MULTI SPECIALITY / TEAM APPROACH.

ADDRESSING THE ETIOLOGY (CAUSE), RESOLUTION FOLLOWED BY PREVENTION.

For example, an ulceration on the bottom of the foot requires offloading with proper shoe devices and modifications, x-rays, cultures, possible MRI to rule out abscess formation and or bone infection requiring surgery and hospital admission.

BENEFITS OF WOUND CARE CENTERS AND VISITING HOME CARE NURSES.

WHY IS MY CARE IMPORTANT?

WHY DO DOCTORS “DEBRIDE” CUT OFF TISSUE EVERY TIME I SEE HIM OR HER? IS THAT MAKING MY WOUND WORTH OR BETTER?

VARIOUS OINTMENTS, HYDRO GEL, SILVADENE CREAM, WET TO DRY DRESSING (SALINE WATER DAMPED ON THE GUAZE) AND OTHER SYNTHETIC LOCAL WOUND CARE DRESSINGS SUCH AS AQUACEL AG SILVER DRESSING, MEDIHONEY, HYDROFERA BLUE, etc.

OTHER DRESSING SUCH AS THE BIOLOGICALS SUCH AS Oasis matrix dressing extra cellular matrix derived from porcine intestine which comes in 3.0cmx3.5cm sheets.

WOUND VACCUM (NEGATIVE PRESSURE).

SKIN GRAFTING AND OTHER SOFT TISSUE FLAP CLOSURE SUCH AS ROTATIONAL, TRANSITIONAL AND ADVANCEMENT FLAP CLOSURES.

LASTLY, COMPRESSION WITH EITHER MECHANICAL PNEUMATIC DEVICES AND OR KNEE HIGHS AND OR ABOVE KNEE SOCKS.  WHAT’S THE DIFFERENCE?

GRADIENT OF PRESSURE REQUIRED?

HOW DO I PUT THEM ON? THEY ARE VERY TIGHT?

I HAVE ARTHRITIS IN MY HANDS, IS THERE AN EASIER WAY TO PUT THEM ON?

I APPRECIATE YOUR TIME AND PLEASE REMEMBER TO LOOK DAILY AT YOUR FEET.

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