Diabetic Foot Ulcer

Definition of Diabetic Foot Ulcer

 foot affected by ulceration that is associated with

neuropathy and/or peripheral arterial disease of the lower
limb in a patient with diabetes
 Pathophysiology of DFU

1/ Neuropathy
-main contributor to the DFU
-sensory disfunction leads to lack of protective sensation
-autonomic dysfunction leads to drying of skin due to lack
of normal glandular function

2/Angiopathy
-reduced blood flow due peripheral vascular disease
 Approach to diabetic foot

 History
 Physical Examination

 Investigations

-biochemical investigation
-imaging
-vascular investigation
-neurological investigation
 History

 General and medical history

-duration of problem,dose of the medication,social
history,other complications of diabetes

 History of foot problem

-footwear,foot care,deformities and previous surgery of
similar complaint
 History of foot ulcer
-site,sizde,duration,odour and type of discharge
-precipitating event or trauma
-recurrence
-previous history of hospitalisation
-wound care-patient compliance
-features of charcoat’s joint
 Physical examination
 General examination-pyrexia,ascending
infection,lymphangitis and sepsis
 Local examination
-attitude and posture of lower extremities
-deformities
-reduced joint mobility
-skin appearance-thinning,hair,fungal infection
-calluses
-nail
 Vascular status of the lower limb

 Pulses(dorsalis pedis,posterior tibial,popliteal,femoral)

 CRT
 Venous filling time
 Edema,difference in temp
 Skin colour
 Ischemic changes-skin atrophy,nail atrophy,reduced
pedal hair
 Ankle-
Brachial
indices(ABSI
)
 ABSI

 Patient in supine position

 The cuff is applied proximal to the artery in question
 Inflate the cuff until the doppler reading ceases
 The cuff is then slowly released until the artery is
detected in the doppler reading
 Measurement of the ABSI is by dividing the ankle systolic
by the brachial systolic
 Neurological Status of lower limb

 All the sensation-vibration,pain,touch,pressure and two

point discrimination
 Deep tendon reflexes
 Clonus testing
 Babinski test
 Romberg test
 Monofilament test

 Monofilaments also known as Semmes-weinstein are used

to assess the risk of ulcer
 Used to assess the pressure sensation perception
 Loss of pressure sensation is associated with risk of
subsequent ulceration
 Biochemical Investigations

 Fasting/random blood sugar

 Glycohemoglobin
 FB
 ESR
 RP
 Blood and wound CNS
 Ulcer examination

 Location,size,depth,margin,swelling,colour,odour,base,flo
or,type of discharge
 Probing of the ulcer is also important aspect of the ulcer
assessment-to look for extension to bone,sinus tract,joint
and tendon sheath
 If cultures are to be taken it must be taken from deeper
tissue as any superficial wound culture are often
misleading and inaccurate
Classification
of diabetic
foot ulcer
 University
of Texas
classificatio
n
 Principles of Treatment

 Debridement of necrotic tissue

-removal of all non-viable tissues and slough from the ulcer
-incision and drainage is done in case of diabetic foot
abscesses
-osteomyelitic bones,joint infection and gangrene would
require resection/amputation
-other forms of debridement includes enzymatic
debridement and autolytic debridement
Wound Care
-important aspect of diabetic foot ulcer
-type of dressing used are determined by the wound
size,depth,location,surface and discharge
-hyperbaric oxygen therapy-insufficient evidence to
support its use
 Off Loading
 Reduce the plantar pressure-helps to reduce trauma to the
ulcer allowing it to heal
 Methods for off loading:
-total non weight bearing
-total contact cast
-foot cast or boot
-removable walking braces with rocker bottom soles
-total contact orthoses-custom walking braces
-patellar tendon or wedges shoes
-half shoes or wedge shoes
-healing sandal-surgical shoe with molded plastizote insole
 Vascular management of DFU

 Any clinically suspicious lower extremity ischemia should

be fully investigated before embarking in any definitive
foot surgery
 Prevention of Diabetic Foot Ulcer

 Education
-importance of daily foot inspection and early intervention
-hyperglycemic control
 Foot care

 Therapeutic shoes

 Off loading

 Surgical correction of deformity