Ms Jan Armstrong Head of Department Consultant Orthopaedc Surgeon - - PowerPoint PPT Presentation
Professor Gary Hooper Mr Gordon Burgess Ms Jan Armstrong Head of Department Consultant Orthopaedc Surgeon Charge Nurse Manager Orthopaedic Surgery Canterbury District Health Board Orthopaedic Outpatient Department Musculoskeletal Medicine
Head of Department Orthopaedic Surgery Musculoskeletal Medicine Christchurch School of Medicine
16:30 - 17:25 WS #46: Dealing with lower limb problems secondary to Diabetes 17:35 - 18:30 WS #56: Dealing with lower limb problems secondary to Diabetes (Repeated)
Consultant Orthopaedc Surgeon Canterbury District Health Board
Charge Nurse Manager Orthopaedic Outpatient Department CDHB Christchurch
Jan Armstrong RGON, BA (Cant) Charge Nurse Manager Orthopaedic Outpatient Department CHRISTCHURCH HOSPITAL
J is a 38 year old who has had diabetes for 13 years. She has been known to our Service since 2014 She has had had 2 formal surgeries for her foot during this time, and some
further admissions for infection flare ups over this period
She has to wear steel-cap boots in her job, which involves standing a lot, she
has had considerable time off work as we have tried casting her foot over these years to offload her ulcerated foot area to gain sufficient healing - to allow her to go back to work in custom-made boots.
She is reluctant to have further surgery, as can’t afford more time off work.
J’s foot appearance prior to debridement by the Diabetic Podiatrist, just after it has come
Patients wash their foot in a disposable basin between cast
provided with shower stools and plastic bags as necessary, to keep their cast dry
J’s foot with an absorbent dressing applied after debridement, which stays
cast. A variety of dressings are used, including silver – depending on the condition
amount of exudate.
Note the high instep in J’s foot, which causes
when she is out of cast
Due to insensate feet often being present in Diabetics, we always enclose the whole foot in the cast, with padding between the toes. We have found with the whole foot in the cast wounds also seem to heal more quickly.
We need to
deformities and create a flat surface for the patient to weight-bear in their cast
We always use cotton liner and padding under these casts
The toes are always well protected with padding and foam so they do not develop pressure areas under the cast
Limbs become quite wasted with prolonged casting so we always protect all bony areas with felt over the top
Additional foam is placed around the top
comfort
A layer of semi-rigid synthetic (Softcast) is applied first under the hard synthetic layers, to avoid any swelling issues, and the likelihood of the cast being applied too tightly around the toe area.
Strips of Synthetic F/Glass are then applied during casting to reinforce the foot area which takes the greatest impact whilst the patient is walking
Patients have a large choice of plain or pattern synthetic casting product to choose from.
The assistant who is holding the patient’s foot in a neutral 90 degree position, is of equal importance to that of nurse applying the Charcot cast. The foot holding can be a challenge if the patient has a significant foot or ankle deformity, but being able to mobilise safely in comfort is crucial for all our patients.
A shoe is fitted, and J then waits for 20 minutes for the cast to set sufficiently for her to walk out of the Department. J will return weekly for changes of cast, until her wound has healed sufficiently to progress to some form of footwear.
For patients who do not have wounds, but are being treated in Charcot casts for Charcot arthropathy, come to the department every 2 or 3 weeks for changes of cast. A cast can take 30 – 45 minutes to apply depending on the complexity - whether patients have a wound or very deformed foot. The Diabetic Podiatrists attend all our clinics and debride any wounds and trim a patient’s nails before casts are re-applied We also have regular input from our Orthotic Service who take moulds of the patient’s foot to provide custom-made insoles to go into the patient shoe or Moonboot, which they wear once the casting period is complete. It is vital to have a multi-disciplinary approach to these complex patients, and skilled staff who are able to competently apply casts which do not cause pressure areas, and allow patients to remain mobile in their homes. Most importantly expert medical input from
challenges is vital.
Staff get to know these patients well over their journey, and help provide support and encouragement, and always check with the patients if they had any issues with their previous cast! There is often a social and financial impact for these patients. Their condition is not ACC-related, and if the cast is applied on their right foot they are unable to drive, which can be socially isolating, and they may even lose their employment. Patients can potentially become quite depressed with their ongoing cast treatment
We encourage the patients to speak to others attending the weekly clinics who are also on a similar journey. We are fortunate to have an 8 bedded Plaster Room, and so patients have an opportunity to engage with each other if they wish. Our greatest sense of achievement is when the patients whom we’ve casted for many weeks or months are successfully healed, and do not need to return for future input from our service.