Next step: Apply a cast
A total contact cast is often utilized to relieve the pressure on the prone portion of the foot. As edema of the affected lower limb decreases over the first week, you’ll need to remove the cast and reapply another. Afterward, you can change the cast every 2 to 4 weeks. Recasting can continue for up to 4 months, with interval radiographs recommended every 4 to 6 weeks during this process.2
When the extremity is no longer swollen and erythematous, you can transition the patient to an ankle foot orthosis or patellar tendon-bearing brace. Surgical options include resecting bony prominences, osteotomies to re-approximate normal anatomy, and amputation.
Getting our patient back on her feet
Once we learned that our patient’s biopsy was negative for osteomyelitis, we began treating her with IV vancomycin for her resistant wound infection. We debrided the pressure ulcer for necrotic tissue.
We initially applied Accuzyme ointment, covered it with Telfa pads, and wrapped it in Kerlix. But the patient developed sensitivity to the Accuzyme, and after discussion with podiatry, we continued her wound care with wet to dry dressings alone for further debridement until cellulitis resolved. (Moist healing is usually recommended to allow new tissue growth.)
While we did not treat our patient’s pressure ulcers with casting, our plan was to do so when the infection resolved. The patient stayed in the hospital for 6 days and was discharged home with 4 weeks of IV vancomycin via a PICC.
Correspondence
Daniel L. Stulberg, MD, University of New Mexico, Department of Family and Community Medicine, MSC 095040, Albuquerque, NM 87131-0001; DStulberg@salud.unm.edu