Foot ulcers in the diabetic patient, prevention and treatment

Abstract

Lower extremity complications in persons with diabetes have become an increasingly significant public health concern in both the developed and developing world. These complications, beginning with neuropathy and subsequent diabetic foot wounds frequently lead to infection and lower extremity amputation even in the absence of critical limb ischemia. In order to diminish the detrimental consequences associated with diabetic foot ulcers, a common-sense-based treatment approach must be implemented. Many of the etiological factors contributing to the formation of diabetic foot ulceration may be identified using simple, inexpensive equipment in a clinical setting. Prevention of diabetic foot ulcers can be accomplished in a primary care setting with a brief history and screening for loss of protective sensation via the Semmes-Weinstein monofilament. Specialist clinics may quantify neuropathy, plantar foot pressure, and assess vascular status with Doppler ultrasound and ankle-brachial blood pressure indices. These measurements, in conjunction with other findings from the history and physical examination, may enable clinicians to stratify patients based on risk and help determine the type of intervention. Other effective clinical interventions may include patient education, optimizing glycemic control, smoking cessation, and diligent foot care. Recent technological advanced combined with better understanding of the wound healing process have resulted in a myriad of advanced wound healing modalities in the treatment of diabetic foot ulcers. However, it is imperative to remember the fundamental basics in the healing of diabetic foot ulcers: adequate perfusion, debridement, infection control, and pressure mitigation. Early recognition of the etiological factors along with prompt management of diabetic foot ulcers is essential for successful outcome.

Figure 1

Obtaining ankle brachial pressure index.

Figure 2

Use of 128 Hz tuning fork.

Figure 3

Semmes Weinstein monofilament. The monofilament is applied perpendicular to the skin until it bends or buckles from the pressure, left in place for approximately one second and then released.

Figure 4

Neuropathic foot ulceration secondary to excessive pressure (from foot deformity) in combination with the repetitive stress from daily ambulation.

Figure 5

Debridement of wound margins to mitigate the “edge effect”.

Figure 6

Total contact cast.

Figure 7a

Removable cast walker.

Figure 7b

Instant total contact cast: made by wrapping the removable cast walker with a layer of cohesive bandage.

Figure 7c

Instant total contact cast: made by wrapping the removable cast walker with a layer of plaster of paris.