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Limb at Risk Evaluation

Diagnosis/Definition

• Limb at Risk is a general term used to describe a variety of foot problems related to comorbid conditions that may result in limb loss if unmanaged. These complications range from skin fissures to large non-healing ulcers that commonly originate from shoe related blisters, corns, or unidentified trauma and may potentially lead to amputation.

• Other factors that contribute to foot complications include: peripheral neuropathy, deep or superficial infections, structural changes and deformities, arterial insufficiency, and venous insufficiency.

Initial Diagnosis and Management

Risk Factors:

• History of Rheumatoid Arthritis

• Bone or joint deformity

• Lower extremity rheumatoid nodules

• History of lower extremity ulcer/ wound

• History of partial foot/toe amputation

• Foot deformity

• Neuropathy, or decreased sensation

• Absence of pedal pulses

• Compromised skin integrity

• Compromised Nutritional status

• Sacral decubitus ulcer

• Lower extremity cellulitis/ infection

• Deep space infection of the foot/ ankle/ leg

• Disability affecting normal lower extremity movement, balance, transfer, etc.

• Poor glycemic control, HbA1C >8

• Autoimmune process (scleroderma)

• Neuro-muscular disease processes’

• End stage renal disease

• Post-burn contractures

• Post surgical sites of lower extremity, i.e. post venous harvest site

• Deep vein thrombosis (DVT) history

• Vascular compromise (their shiny skin; edema; varicose veins, etc.

• Charcot foot (see CHARCOT FOOT REFERRAL GUIDELINE)

Physical assessment of the foot to include:

• Presence of ulceration

• Absence of pedal pulses

• Loss of protective threshold diagnosed with monofilament or vibratory testing

• Presence of foot deformity

• Signs of lower extremity infection

• Decreased muscle strength

Ongoing Management and Objectives

To decrease the rate of toe, foot, and lower extremity amputation with proper referral of those patients considered to be at high risk for developing limb threatening conditions to a group of specialists who focus on mechanical, medical, and surgical intervention in the treatment of limb threatening complications.

Indications for Specialty Care Referral

After the PCP has evaluated the patient and performed a structured foot screening, patients with any of the following should be referred to the Limb Preservation Service/Wound Care Clinic with Mary Anne Landowski, RN who will perform a detailed foot evaluation and analyze for appropriate care:

Diabetic patients with moderate to high risk for ulceration (determined by foot at risk screening process).

Patients with a combination of one or more of the signs and symptoms identified in the Initial Diagnosis and Management above.

Criteria for Return to Primary Care

After any acute problem has been appropriately treated.

Patients found to be at high risk should be followed in the Limb Preservation Service/ Wound Care Clinic at intervals determined by the clinic providers in conjunction with the Primary Care Provider. These follow-up intervals will change based upon the progression or regression of the complications identified in each specific patient.

All patients should be followed by the primary care provider for treatment of all co-morbid conditions and routine care with the goal of optimal health and wellness for the whole patient.