Q. I met a C7 quadriplegic who had returned to the hospital to have two of his toes removed because they had become infected and the infection had gotten into the bone. He said the whole thing started when he was wheeling around without shoes on a hot summer day and got a minor scrape on them. He didn’t think it was a big deal, but it really freaked me out. Is this something that happens often? What can I do to prevent it?
A. Chris, I wasn’t able to find statistics on how often this happens, but I know friends who’ve had toes amputated for the same reason. Because SCI often results in reduced blood flow to legs and feet, a minor scrape or cut on a heel or toe heals slower, which leaves an opening for bacteria to cause serious infection that can spread to the bone — osteomyelitis. Although the thought of losing a toe is bad enough, if the infection spreads, more area may need to be amputated. The best and easiest way to avoid this is by wearing shoes — something we often overlook, especially during summer.
In his younger years, Eric Stampfli. 53, now in his 36th year as a T11 para, lost two toes on his right foot and four on his left foot this way. “I used to go barefoot a lot and would stub or scrape a toe. It would get infected and eventually would get into the bone and require amputation. Usually the amputation was just the tip of the toe which left a stub, but sometimes it was the whole toe,” he says.
The first amputation didn’t look infected. “It just wouldn’t close up and heal,” he recalls. After a year and a half trying to heal the toe, Stampfli’s primary care physician tested him for diabetes, which came back negative. “By chance I saw my orthopedic surgeon for something else and I mentioned my toe. He ordered a sed rate test (erythrocyte sedimentation rate — a blood test to help identify the inflammation response of the immune system). The sed rate test came back elevated — a sign of bone infection. An X-ray showed that half the bone of the big toe was already gone because of osteomyelitis. A week later Stampfli’s big toe was amputated under general anesthesia.
In Stampfli’s subsequent toe amputations, he went without anesthesia. “It is an outpatient procedure. I go in, they amputate the toe, sew it up and send me home. The only bad part is the sound when they clip through the bone.” He also understands he is fortunate that he caught the infections before they spread further, something that could have required amputation of part or all of his foot. “I’m a lot more protective of my feet these days. I always wear shoes. I see lots of paras wheeling around without shoes or wearing sandals and I just cringe, knowing how easy it is to scrape your toes.”
Without sensation, minor cuts and scrapes are easy to miss — one of the reasons daily skin checks are so important. If you do get a minor cut or scrape, MayoClinic.com offers solid advice (see resources) to help in healing and avoid infection: rinse the wound with clear water; avoid getting soap directly in the wound as it can irritate it; if any dirt or debris remains in the wound, carefully remove it with tweezers (cleaned with alcohol). If there is still debris in the wound, it is a good idea to see your doctor. After the wound is clean, apply an over-the-counter antibiotic ointment like Neosporin, Polysporin or Bacitracin to keep the surface moist and discourage infection. Cover the wound with a bandage and change it daily or whenever it becomes wet or dirty.
A cut or scrape is a good time to make sure you are up to date on your tetanus shot, recommended every 10 years. The Mayo Clinic suggests speaking with your doctor if your last tetanus shot was more than five years ago and the wound is deep or dirty.
Diana Elledge, RN, Craig Hospital SCI Nurse Advice line, lists signs that may indicate a cut or scrape has become infected and warrant seeing a physician — surrounding skin that is warmer or cooler to the touch or is pink or red (purple if darker skin); an area around the wound that feels baggy or mushy or is developing edema; an increase in spasticity; signs of autonomic dysreflexia; a wound that fails to heal in a timely manner. An especially important sign of infection is an area of discolored skin that is quickly spreading outward (over a period of hours) or travels out in streaks. This could be a sign of cellulitis — a serious and potentially life-threatening bacterial infection. See a physician immediately if this happens.
Summertime Skin Tips
Summer sun and heat hold other dangers for people with compromised sensation, says Elledge. “In the summer we get calls from people who have gotten burns transferring onto hot car seats that have been sitting in the sun or other surfaces that get hot in the sun, like seatbelt buckles. The same danger holds true transferring to a wheelchair that has been sitting in the sun.”
Be aware of sunburn, especially if you wear shorts and sandals. Compromised sensation combined with sitting in shorts and sandals puts thighs, knees, and the top of feet in direct sunlight — a set-up for severe sunburn. At minimum it is important to slather on plenty of UVA/UVB sunscreen to these areas. Another option is to wear shorts or pants that cover the knee. Additional important information on sun protection can be found at the Craig Education Module (see resources).
Also, be cautious of cuts and scrapes to feet and knees that happen all too easily while frolicking in swimming pools, rivers or lakes, or near ocean coral or rocks. An inexpensive way to avoid this is to wear socks while swimming, or cut up an additional pair of socks to wear on your knees. A cool way to protect feet and knees while swimming is to wear neoprene fin socks (available at dive shops, surf shops and online for around $10), and knee sleeves (available at sporting goods stores or online for around the same price).
Last but not least, when you lift yourself out of the water, be careful not to sit on surfaces that heat up in the sun, like metal grates or dark surfaces. Hot surfaces can quickly cause a serious burn through a wet swimsuit. Sitting on your wheelchair cushion with a folded towel is the best way to protect your skin. Although it may seem like overkill at the moment, taking these precautions beats spending the rest of the year healing up a scrape, burn or pressure sore.
• Craig Education Module on Sun Protection; www.craighospital.org. Click on SCI & TBI Health Info and choose Education Modules. Click on Skin. Click on Sun Protection.
• Cuts and Scrapes: First Aid; www.mayoclinic.com/health/first-aid-cuts/FA00042
• Understanding Cellulitis; www.newmobility.com/2011/05/paramedic-understanding-cellulitis/
Advice in this column is supported by Craig Hospital’s SCI Nurse Advice Line, a toll-free hotline for people living with SCI, a community service partially funded by grants from the PVA Education Foundation, Craig H. Nielsen Foundation and Caring for Colorado Foundation. For non-emergency nursing information about SCI health, call 800/247-0257 between 9 a.m. and 4 p.m. Mountain time. If you have a health question, contact Bob Vogel at firstname.lastname@example.org.