Neuropathic Ulcers (not on Sofia)

Question 1

What is a neuropathic ulcer?

Answer 1

Neuropathic ulcers form as a result of peripheral neuropathy, typically in diabetic patients. Local paresthesias, or lack of sensation, over pressure points on the foot leads to extended microtrauma, breakdown of overlying tissue, and eventual ulceration.

Question 2

Are neuropathic ulcers painful? When do they present?

Answer 2

No - they are caused by a loss of sensation which predisposes to constant trauma and so they are not painful. Therefore they present late.

Question 3

What symptoms are associated wih a neuropathic ulcer?

Answer 3

• Associated with sensory loss
• so may also present with unsteady gait
• Often secondary infection –> foul smell (caused by anaerobes)

Question 4

Name 2 risk factors for neuropathic ulcers

Answer 4

• Diabetes mellitus
• Alcohol overuse
• Poor foot care

Question 5

What is the typical site of neuropathic ulcers? What are the characteristics?

Answer 5

Site:

• Caused by repetitive trauma so found in areas where the foot has lost sensation so on pressure areas/where feet rub on poorly fitting footwear (beneath metatarsal heads)

Characteristics of neuropathic/pressure ulcers:

• thick/keratinised, raised edges surrounding them (thickened skin is called a callus)

Question 6

What signs are associated with neuropathic ulcers on examination?

Answer 6

• Loss of sensation - vibration and proprioception lost before other modalities
• Glove and stocking distribution of peripheral sensory neuropathy
• Foot deformities - due to motor neuropathy or repetitive joint trauma secondary to neuropathy (Charcot joints)

Question 7

How do you manage a neuropathic ulcer?

Answer 7

1. Foot care - avoid tight shoes, examine feet daily, regular podiatry review, have shoes made by orthotics team
2. Manage diabetes - uncontrolled hyperglycaemia will hinder ulcer repair ad fighting infections
3. Debridement - of necrotic tissue which tends to build up, using special bandages (hydrogel sheets) or surgically.
4. Treat infections

Question 8

What is a serious complication of a neuropathic ulcer?

Answer 8

Osteomyelitis - exclude this by taking a plain film and checking for bony deformity, air in the soft tissues, signs of osteomyelitis (e.g. osteolysis - reduced opacity; periosteal reaction suggesting formation of new bone from cortex outwards)

If X-ray is inconclusive then MRI