Assessment and Management of a Foot Ulcer

Question 1

What is the most common reason for a pt with diabetes to be admitted to hospital?

Answer 1

Foot ulceration (also the most common indication for amputation in the entire population)

Question 2

What microvascular complications are relevant to the development of a diabetic foot ulcer?

Answer 2

Sensory neuropathy: loss of sensation leading to trauma, instability
Motor neuropathy (often later): wasting of intrinsic muscles of foot, wasting of long flexors and extensors, reduced joint mobility (all contribute to “clawed” deformity of foot which can cause pressure ulcers)
Autonomic neuropathy: sweat glands (dry skin, leads to cracking), small arteries and veins (AV shunting)

Question 3

What diabetic complications are relevant to the development of a foot ulcer?

Answer 3

Neuropathy (both sensory and mechanical deformity)
PVD
Increased susceptibility to infection

Question 4

Diabetes>immunosuppression?

Answer 4

?

Question 5

What organisms are typically seen in diabetic foot ulcers? How does this mean for treatment?

Answer 5

Typically polymicrobial: skin commensals, anaerobes, Gram negatives
Requires broad spectrum Abs; may need drainage and debridement

Question 6

How can tissue perfusion be assessed?

Answer 6

Clinically: signs of perfusion (Ps), palpation of pulses (can help localise arterial disease), ABI (not reliable if artery is calcified and therefore can’t compress tibial vessels), toe pressure (more accurate in the case of calcification; good indicator of arterial potential of wound healing), duplex US?

Question 7

Relevance of nephropathy to management of diabetic foot ulcer

Answer 7

Can impact healing

Impact of contrast if ordering angiogram

Question 8

Removing pressure from ulcer sites

Answer 8

Plaster cast is gold standard treatment but usually not first-line due to evidence of infection
Boot, usually with padding on bottom of foot or around ulcer
Post-op surgical shoe if not tolerated

Question 9

4 stages of pressure ulcers

Answer 9

1: Non-blanching erythema
2: Closed fluid-filled blister
3: Erupted blister
4: Bone and tendon visible
May be maroon with suspected deep tissue injury
May be unstageable if lots of slough and necrotic tissue

Question 10

Offloading pressure ulcers

Answer 10

Air mattress

Elevation of leg: soft boot with heel hanging out

Question 11

Positive swab for e.g. Pseudomonas: diagnostic for infection?

Answer 11

Not diagnostic, could just be colonisation

Diagnosis of infection requires markers of infection, both clinical and on further Ix

Question 12

ALP reliable marker of osteomyelitis?

Answer 12

No, not used clinically