NORTHEAST OHIO NEIGHBORHOOD HEALTH SERVICES, INC. PODIATRY 2012-2013 CLINICAL GUIDELINES TABLE OF CONTENTS CONDITION PAGE(S) Diabetes Mellitus and Podiatric Care 2 Fractures 3-4 Heel Pain (Posterior) Retrocalcaneal Spur 4 Heel Pain (Inferior) Plantar Fascitis 4 Heel Spur Syndrome 5 Morgon s Neuroma (Interdigital Neuroma) 5 Onychomychosis 5 Onychocryptosis (Paronychia) 5 Peripheral Vascular Disease 6 Tinea Pedis 7 Venous Stasis Ulceration 7 Verruca Plantaris 7
NEON PODIATRIC MEDICINE CLINICAL GUIDELINES: 2012-2013 The following collection of clinical guidelines has been adopted by NEON clinicians. The guidelines cover common conditions that are managed in our practice settings. This collection is not intended to be an all-inclusive list. Clinical parameters employed in our clinical performance audits shall be derived from the guidelines herein stated. These guidelines are updated on an annual basis. Diabetes Mellitus and Podiatric Care Bi-monthly nail and foot care should be arranged for and advised to the patient. Daily inspection and lubrication of feet (not between toes) should be encouraged in all patients. Dermatological, neurological, and vascular evaluations should be performed yearly and when otherwise indicated. Inspection of shoe gear should be performed as part of each podiatric encounter. Ulcer or wound Management: All obvious non-viable tissue must be removed surgically, unless severe vascular embarrassment exists. Dressing changes: Clinical dressing changes should be coupled with home dressing changes. If patient is unable to self-manage home dressing changes, arrangements should be made for the provision of visiting nursing services. A nuclear Bone Scan should be used to detect bone involvement, if osteomyelitis is suspected in association with slow healing diabetic ulcerations. Evaluate for the presence or degree of diabetic neuropathy (deep tendon reflexes, propioception, soft touch, and sharp/dull sensation). Patient should be educated to wear the correct shoe gear. Page (2)
Fractures Calcaneal Fractures: A. Extra-articular Calcaneal fractures. Anterior process: Posterior tuberosity: Oblique and lateral foot radiographs are necessary to diagnosis. Treatment generally consist of ice, compression bandage, elevation, immobilization initially. Ambulation permitted per tolerance. Calcaneal axial radiographs are necessary. Treatment for undisplaced fracture is BK - WB cast for six weeks. Treatment for displaced fracture is ORIF then BK-WB cast for six weeks. Sustentaculum Tali: MO radiograghs of the foot are indicated. Treatment is BK - NWB cast for six weeks. Beak fracture: Radiographs of the lateral foot are indicated. Treatment of undisplaced fracture is BK - NWB case for six weeks. Treatment of displaced fracture is ORIF and BK NWB cast for six weeks. Avulsion fracture of the Achilles tendon: Radiographs of the lateral foot are indicated. Treatment is ORIF and BO-NWB case six to eight weeks Oblique Fracture through body of Calcaneus Radiographs of the lateral calcaneal axial are indicated. Treatment for an undisplaced fracture generally consist of compression dressing NWB with early active motion exercises on hourly basis for 8--12 weeks. Treatment for a displaced fracture (Bohler s angle < 10) close reduce with K-wire and AK cast four weeks, remove wire, then treat as undisplaced fracture. Page (3)
B. Intra-articular Calcaneal fractures: Fractures involving the subtalar joint; Comminuted fractures. Metatarsal Fractures: Depending on radiographic findings treatment of intra-articular fractures involve the following: Early mobilization; Closed reduction; Open reduction; Primary subtalar or triple arthrodesis. Radiographs of the AP MO lateral foot are indicated; Treatment of an undisplaced fracture is BK NWB for four weeks followed by BK-WB cast for four weeks; Treatment of a displaced is ORIF - BK NWB six to eight weeks Heel Pain (Posterior) Retrocalcaneal Spur Diagnosis is made with the assistance of foot radiographs and clinical presentation. Padding; Therapeutic injections; Physical therapy; Surgical excision of exostosis/bursa. Heel Pain (Inferior) Plantar Fascitis Diagnosis is made with the assistance of foot radiographs and clinical presentation of inferior calcaneal pain. Therapeutic injections; Low dye strappings; Orthotic appliances; Physical therapy; Weight reduction (in overweight individuals) endoscopic plantar fasciotomy when indicated. Page (4)
Heel Spur Syndrome Diagnosis is made with the radiological evidence of an exostosis of the calcaneal process along with clinical presentation of inferior calcaneal pain. Therapeutic injections; Low dye strapping; Physical therapy; Orthotic appliances; Surgical excision of exostosis endoscopic plantar fasciotomy when indicated. Morgon s Neuroma (Interdigital Neuroma) Orthoses; Padded insoles; Shoe style changes; Therapeutic injection; NSAID - physical therapy; Neurectomy when indicated. Onychomycosis After assessment of patient the following should take place: Debridement of nails is advisable on a bi-monthly basis. Oral therapy should be considered and is preferred over topical; medications which are at best marginally effective. Onychocryptosis (Paronychia) Goal: removal of offending nail growing into the skin. Assess for secondary pyogenic infection. After assessment of patient s vascular status, management should include the following: After digital nerve block and sterile preparation, avulsion of the offending nail border is indicated; Apply wet dressing for relief of the inflammation; Antibiotic therapy to control pyogenic infection. Page (5)
Peripheral Vascular Disease ASO/PVD If PVD is suspected, the lower extremities should be evaluated for the following clinical findings: Vascular signs of reduced flow: reduction/loss of pulses; prolonged capillary filling times; edema; thrill. Dermatological signs of reduced flow: reduced skin tone; atrophy; dry/scaling; loss of hair on dorsal feet/toes; dystrophic nails; ulcers; reduced skin temperature; pale/bluish/ruborish skin color. Refer patient for Ankle/Brachial Index and pulse volume recordings Ankle/Brachial Index thresholds are as follows: 0.9 > 1 = Normal 0.7-0.9 = Single occlusion/mild disease 0.5-0.7 = Single occlusion/moderate disease < 0.5 = Multiple occlusions/severe disease Bi-monthly nail and foot care are advisable. Daily inspection and lubrication of feet (not between toes) should be encouraged in all patients. Inspection of shoe gear should be performed. Increased physical activity (e.g. mall walking) should be encouraged in all patients per their tolerance and abilities to promote collateralization of blood flow Pentoxifylline may be of use in this setting. In coordination with the primary care physician, refer the patient to a vascular surgeon for management assistance. Page (6)
Tinea Pedis T. rubin diagnosed on soles and sides of the feet are preferably treated with topical application of an antifungal cream. T. rubin diagnosed in web spaces is preferably treated with imidazole antifungals. Venous Stasis Ulceration Goals of management are as follows and should be reflected in the medical record: Reduce the Ambulatory Venous Hypertension; Restore skin integrity; Maintenance of healed status; Referral for circulatory status assessment. Management should include the following components: Reducing edema; Elevation of extremity; External Support -- Unna boot dressings, Jobst stockings, ace wrap; Debride necrotic tissue; Inspection for and treatment of infection. Verruca Plantaris After assessment of patient: Conservative treatment generally includes applications of keratolytic preparations along with debridement. Surgical treatment generally involves blunt curettage as the procedure of choice to prevent scarring. Page (7)