Another Useful Tool from BioMedix!

Last week we discussed PAD and the non-invasive vascular studies that can be completed in our office to help with diagnosing PAD. Through the BioMedix Collaborative Care Network, communication between your medical team can be facilitated. Chronic Venous Insufficiency (CVI) is another vascular related problem (covered on the BioMedix Website) that non-invasive vascular studies can help to diagnose, but it differs from Peripheral Arterial Disease in its location within the body’s blood vessels. As the name implies, CVI is a condition that results from damage to the veins or venous flow within the body, where as we learned last week, PAD is disease of the arteries.

Veins located throughout the body are responsible for bringing blood from locations furthest from the heart back up to the heart, for recycling and re-oxygenation by the lungs. This prepares the blood to again circulate through the body and carry oxygen out to the tissues. Located within the bodies veins are tiny one-way valves which when the blood is being transported back up to the heart, help pump the blood upwards while closing off with each beat of the heart to prevent backflow of the blood with gravity. When those valves become damaged, patients suffer from Chronic Venous Insufficiency, where the body has difficulty pumping blood through its veins back up towards the heart.

Patients will slowly notice an onset of symptoms including painful, swollen and “heavy feeling” legs. They will notice that their legs begin to feel tired or restless at the end of a long day, which is something they have not experienced before. In addition, patients may start to notice varicose veins and veins bulging through the skin as the pressure building up within them predisposes them to enlargement.

Other associated symptoms and conditions may include skin discoloration, dry scaly skin along the legs and feet and breakdown of the skin if the buildup of extra fluid in the legs becomes too great. Breakdown of the skin typically presents in the form of a “Venous Stasis Ulceration,” which basically means what we’ve been saying: the ulceration is caused by blood located within the venous system of the body that is stuck in the legs and leads to ulceration.

Risk factors for the development of CVI are varied, but some can depend largely on hereditary and the nature of the patient, meaning those that have a family history of CVI or are women over the age of 30 are at a greater risk for development. In addition, patients with a history of blood clots, multiple pregnancies or who do lots of heavy lifting and endure long periods of standing also have an increased risk.

If you present to your Podiatrist with a variety of the risk factors and symptoms consistent with Chronic Venous Insufficiency, your diagnosis may be made by clinical examination alone. However, it is important to undergo Vein Studies to help rule out any larger problems, such as blood clots, in addition to selecting the most appropriate treatment regimen.

We mentioned last week that Advanced Footcare Centers LLP collaborates with BioMedix through a Collaborative Care Network, where vascular testing can be completed and communication can electronically occur between your medical team (Podiatrist, Primary Care Physician and Vascular Surgeons). In addition to including testing for Peripheral Arterial Disease, BioMedix also collaborates on testing and treating Chronic Venous Insufficiency.

The most accurate test is called a Venous Duplex Ultrasound. The test takes an ultrasonic picture of the veins in the body to detect any acute or chronic blockages in addition to evaluating the status of your veins one-way valves. Once any acute blood clot has been ruled out and Chronic Venous Insufficiency has been diagnosed, there are a variety of treatment options available. Some treatments can be done by you at home, such as maintaining a healthy diet and exercising regularly to increase the competency of your legs muscle pump to help bring blood back to the hear easier. Compression stockings are often encouraged for patients without any history of congestive heart failure and for those patients that stand for long periods of time, as the compression will help the legs bring blood back up towards the heart rather than becoming stuck in the legs. Medications such as diuretics can be used to decrease some of the fluid build-up, but as always, before any of these treatments are initiated, consult your Podiatrist and your Primary Care Physician.

For more information on Chronic Venous Insufficiency, please click on the link below, which will direct you to the BioMedix Collaborative Care Network!

http://www.biomedix.com/patients/CVI_patient_resources.asp

Non-Invasive Vascular Studies: Take One!

Several months ago I blogged about Peripheral Arterial Disease (April 23, 2010: The Triad That Leads to P.A.D.), which is a disease of the circulatory system where blood flow to the periphery of the body, mainly the legs, is compromised or blocked secondary to a build-up of plaque within the vessel walls. The major risk factors that increase a patient’s chances of developing plaque build-up and subsequent Peripheral Arterial Disease are three: High Blood Pressure, High Cholesterol, and Smoking. Diabetes can also contribute to the disease, but keep in mind that although Peripheral Arterial Disease is commonly seen in the diabetic patient, it is not limited to that patient population alone.

In that blog it was mentioned that non-invasive Vascular Studies could be completed when pulses in the feet were non-palpable to your Podiatrist. These non-invasive tests can help to determine the amount of blood flow, while predicting blockages or occlusions within the main vessels carrying blood to the legs, feet and toes.

The first and most basic test that is typically ordered is called an “Ankle-Brachial Index,” or ABI as it is referred to in the medicine world. This test is performed using a simple blood pressure cuff, first applied around the arm to determine the blood pressure in the arm, and next applied to the calf to determine the blood pressure in the leg. The test is performed with the patient lying flat on a bed, usually on their back and will only take a few minutes to perform. The test is also painless, although some patients may experience minimal discomfort with inflation of the blood pressure cuff, which will be relieved upon deflation.

A second test, and one that is typically performed in conjunction with an ABI, is called a Pulse Volume Recording (PVR). As the heart beats, blood is “pulsed” throughout the body and when measured in the lower extremities by the PVR test, the values obtained can help indicate areas where the blood flows best and areas where there may be disruptions in blood flow. The test is performed by applying multiple blood pressure cuffs at intervals down the legs, and jas with ABI testing; it is a painless exam and is tolerated well by most all patients.

Together the information obtained in the ABI and PVR tests can help determine how well blood is flowing down into the legs and will indicate if there is narrowing or blockage of the vessels in any areas. It will also help determine how progressed your Peripheral Arterial Disease is and will guide treatment of the disease specifically for you!

At Advanced Footcare Centers, LLP Ankle Brachial Indices and Pulse Volume Recordings are completed in the office and your information is electronically sent via BioMedix PADnet, through our Collaborative Care Network. The Collaborative Care Approach ensures that the appropriate physicians managing your care, including a vascular surgeon and your primary care physician, all have access to the information obtained via these tests. Thus, they can work together on finding the best solution to managing your early or progressed Peripheral Arterial Disease.

For more information on the Collaborative Care Network with PADnet and BioMedix, of for more information on Peripheral Arterial Disease, click on the link below. If you have questions or concerns about the blood flow to your extremities, contact your Advanced Footcare Center Podiatrist today!

http://www.biomedix.com/collaborative_care_model.asp

Fun for the Podiatric Surgeon; Not So Much Fun for the Patient!

As a human being, I never want to see anyone get injured, but as a medical professional, if no one ever did, I would be out of a job! So sometimes, injuries are fun to see, as it presents a challenge for determining the best option for treatment. About a week ago a patient came into the Emergency Room with a Type II Gustillo Anderson fracture of the 1^st, 2^nd and 3^rd toes after a car jack slipped and landed onto his foot. (Hopefully you’ll understand what all that means by the conclusion of today’s Blog) It wasn’t much fun for the patient, and I felt bad for the guy as he was a really nice man, but getting to treat his injury was fun!

An open fracture is any fracture that is accompanied by a break in the skin in the area of the boney fracture. The broken bone does not necessarily need to be protruding from the skin, but it often will be. These types of injuries are not exclusive to the lower extremity, but when found there are typically associated with high-energy injuries. Meaning any injury where there is a strong force or impaction as would be the case in falls from a height or motor vehicle accidents for example, or in the case of this patient, direct force to the foot from the car jack.

There are two main ways to look at an open fracture: was the break in the skin caused by something from the outside penetrating inward, or was the break in the skin caused by a bone from inside the body pushing outward? In terms of treatment and managing the fracture site, the answer to this makes little difference, but if the break in the skin was caused by something outside (like a nail or bullet) penetrating inward, you would want to consider whether the patient has an updated tetanus vaccination and what bacteria are commonly associated with the type of object that has penetrated the skin.

If you haven’t picked up on it yet, in the medical profession we love to classify things! Some of our classification systems make little sense, but it gives us a way to communicate with our colleagues in a succinct manner. For open fractures, the classification system used most often is the Gustillo and Anderson Classification. It evaluates open fractures based on: soft tissue coverage and injury to blood vessels, muscles and/or nerves. The classification is as follows:

Type I: An open fracture less than 1cm in size with little soft tissue involvement and no crush of the bone.

Type II: An open fracture that is greater than 1cm in size with minimal soft tissue damage.

Type III: An open fracture that is greater than 5cm in size with extensive soft tissue damage including damage to muscle, nerve and blood vessels.

Open fractures are typically surgical emergencies from a Podiatric Medicine standpoint, meaning we would like to take the patient to the Operating Room within the first 24 hours. Type III injuries would be taken to the operating room sooner than a Type I injury. The goal in taking these patients for a surgical procedure is to clean out the soft tissue eliminating as much dirt and bacteria as possible, to reduce/realign the fracture fragments into their correct “pre-injury” position and to close the skin if possible preventing further infection. If all the goals of surgical intervention are met, it will help decrease the risk of further tissue damage as well as decrease swelling, pain and bacterial spread, getting the patient on the road to recovery!

If we revisit the patient I saw in the ER last week, we can recall that he had a Gustillo-Anderson Type II injury. If we refer to the classification system, we know that the open part of the injury along the digits was larger than 1cm with minimal soft tissue damage. His injury was an “outside to in” type injury, but luckily, the car jack did not break through his shoe, thus there was no foreign body present. He was given a broad-spectrum antibiotic (to cover the most common types of bacteria) and was taken to the OR the following day. One of the bones in the big toe suffered a crush injury and had very little soft tissue coverage, meaning it was in many small pieces and would have been difficult to approximate the skin edges, thus the bone was removed. The bones within 2^nd and 3^rd toes had one fracture line each, so they were reduced and the soft tissue coverage over them was adequate, thus they were closed.

Open fractures are not something we see on a daily basis, and certainly can be detrimental to the patient depending on the severity of injury, but they do provide a welcomed challenge to the Podiatric Surgeon!

For more information on foreign body injuries, refer to our Blog from June 28 entitled: Think Twice Before Kicking Off Those Summer Shoes!

Should Little Girls Wear High Heels?

This past weekend I was at a wedding and just before the bride entered, the cutest 3 year old girl in a white “frilly” dressing, with a green sash and sparkly high-heels walked down the isle spreading flowers in her path. I should have been “oohing and ahhing” at how cute she was, but I couldn’t get over the fact that she was wearing heels!

Several months ago a featured segment on a National Morning News broadcast, addressed the issue of girls from as young as 3 years old wearing high heels. It was mentioned in the segment that these young girls are still undergoing developmental changes, and wearing heels could have implications on proper growth. That is in fact true! The last bones in the foot to solidify, changing over from cartilaginous material to solid bone can take place up to the age of 18 years. Wearing heels at such a young age could have serious implications on growth!

The mechanics of heels are many. They can:

1. Increase pressures on the ball of the foot

2. Increase ankle instability leading to injury

3. Tighten the heel cord creating changes in gait including "toe walking"

4. Induce changes on growth plates, which don't close until late in the teen years, causing developmental complications.

5. Predispose an already destined foot type toward the development of bunion and hammertoe deformities.

Aside from injury to your child’s foot, which should be avoided at all costs, tightening of the heel cord most certainly creates changes in gait including “toe walking.” However, that’s not the only problem that a tight heel cord can induce. If you remember, throughout several previous blogs, including the ones on plantar fasciitis and retrocalcaneal exostosis (“pump bump”), tightening of the musculature in the back of the leg, which is essentially the heel cord, can contribute to multiple foot issues and pain both in the back of the foot and on the plantar surfaces of the foot.

We’ve talked about the mechanics of bunion deformities before and that your foot-type predisposes you to the development of bunions and in fact, hammertoes, all of which proper and supportive shoe gear can help to prevent or slow the progression of. If you’re child wears heels from the age of 3 and has a foot type that pre-disposes them to bunion and hammertoe deformities, they will more than likely develop these deformities much sooner in life, with correction necessary in their early teen years.

Although heels may look "cute," there are plenty of flat shoes out there these days that are also cute! Kids love sparkly and 'jazzy' things, so why not find some sneakers or ballet flats that fall into that category? It simply isn’t worth the risk of injury, developmental complications or the formation of bunions and hammertoes to wear high heels for the fun of it.

In the event that your child wants to wear heels for special events, that’s okay. It is, however, recommended that you limit wear to 4 hours or less and choose heels with a wider toe box and a more stable heel. This will help prevent crushing of the toes as well as help decrease the instability typically associated with a ‘skinnier’ high heel.