II. Pathophysiology

  1. Sensory protection is lost (Diabetic Neuropathy)
    1. Results in chronic Trauma
    2. Tissue breaks down in Traumatized area
    3. Charcot changes result in additional pressure points
  2. Complicating factors (related to poor healing)
    1. Peripheral Vascular Disease
    2. Edema (Venous Stasis, Congestive Heart Failure)
    3. Osteomyelitis

III. Evaluation: General

  1. Evaluate for systemic illness
    1. Cellulitis with SIRS criteria (Sepsis)
    2. Acute Osteomyelitis (typically in children with hematogenous spread) with toxic or ill appearance
      1. Contrast with Chronic Osteomyelitis (typically in adults with local spread) which is slow, indolent
  2. Evaluate for complicating factors
    1. Osteomyelitis
      1. See Suspected Osteomyelitis in Diabetes Mellitus
      2. Erythrocyte Sedimentation Rate (ESR) >60
      3. Affected limb x-ray
      4. Probe-to-Bone Test
    2. Retained Foreign Body
      1. Consider XRay
      2. Consider bedside soft-tissue Ultrasound
    3. Peripheral Vascular Disease
      1. Distal Pulses
      2. Ankle-Brachial Index

IV. Evaluation: Inpatient Criteria for Foot Wound with Limb-Threatening Infection

  1. Extensive Cellulitis (>2 cm)
  2. Ascending lymphangitis
  3. Deep abcesses
  4. Osteomyelits
  5. Gangrene
  6. Critical Limb Ischemia
  7. Probe extends to bone (probe to bone test)
  8. Frykberg (2006) J Foot Ankle Surg 45(5 Suppl):S1-66 [PubMed]

V. Management: Outpatient

  1. Offloading is key
    1. Ongoing Trauma persists until non-weight bearing
    2. Options
      1. Use Crutches, walker or wheelchair
      2. Darko Shoe (half shoe not offloads distal foot)
      3. CAM Walker
      4. Total Contact Cast
  2. Dressings (moist healing is critical)
    1. Dry to minimal exudates
      1. Wet-to-Moist Dressing (cost effective, first line) or other Saline Gauze Dressing
      2. Hydrogel Dressing (e.g. Curasol)
    2. Moderate to heavy exudates
      1. Hydrofiber dressing (e.g. Aquacel)
    3. Other preparations with specific indications
      1. Silver products (e.g. Acticoat) may be considered for infected wounds
      2. Debridement salves (e.g. accuzyme) may be considered for Enzymatic Debridement
    4. Other more complex and expensive options
      1. Promogran
      2. Becaplermin (Regranex)
      3. Bioengineered skin graft
  3. Additional measures
    1. Determine if antibiotics are appropriate
    2. Remove Callus (causes pressure areas)
  4. Measures to avoid
    1. Chronic Wounds without superinfection do not require culture

VI. Prevention

VII. References

  1. Delaney and Khoury in Herbert (2017) EM:Rap 17(12): 2-3
  2. (2014) Presc Lett 21(12): 71

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Ontology: Diabetic foot ulcer (C1456868)

Concepts Disease or Syndrome (T047)
MSH D017719
SnomedCT 371087003
LNC LP98442-4, MTHU029695, MTHU035222
Dutch diabetische voetzweer
French Mal perforant plantaire, Ulcère diabétique du pied, Ulcère du pied diabétique
German diabetisches Fussulkus, Fußulkus, diabetisches
Italian Ulcera di piede diabetico, Ulcera del piede diabetico
Portuguese Úlcera do pé diabética, Úlcera Diabética do Pé
Spanish Úlcera en pie diabético, Úlcera de Pie Diabético, úlcera pédica diabética (trastorno), úlcera pédica diabética
Japanese 糖尿病性足部潰瘍, トウニョウビョウセイソクブカイヨウ
Czech Diabetická noha s vředem, diabetický vřed
Hungarian Diabeteses láb fekély
English Diabetic foot ulcer, diabetic foot ulcer, diabetes mellitus foot ulcer, diabetes mellitus foot ulcer (diagnosis), Diabetic foot ulcer(s), Diabetic foot ulcers, Diabetic foot ulcer (disorder), Foot Ulcer, Diabetic
Norwegian Diabetiske fotsår