Diabetic Foot Ulcers and Pressure Ulcers. Laurie Duckett D.O. Plastic and Reconstructive Surgeon Oklahoma State University Center for Health Sciences

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1 Diabetic Foot Ulcers and Pressure Ulcers Laurie Duckett D.O. Plastic and Reconstructive Surgeon Oklahoma State University Center for Health Sciences

2 Lecture Objectives Identify risk factors Initiate appropriate evaluation and work up Treatment Referral

3 Diabetic Foot Ulcers Most common foot injury that leads to amputation PCP, PA,NP and other health providers play an important role in the prevention,diagnosis and treatment

4 Pathology of a Diabetic Foot Ulcer Peripheral neuropathy motor component-anatomic foot deformity autonomic component-loss of ability to moisturize sensory component-loss of protective sensation

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6 Evaluation of a Diabetic Foot Ulcer History progression of the ulcer etiology of the ulcer previous ulceration

7 Evaluation of a Diabetic Foot Ulcer Size of the ulcer length, width and depth of the ulcer need to be documented Location of the ulcer Dorsally at the base of the toes Plantar on the metatarsal heads and heel area

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9 Evaluation of the Diabetic Stage of the ulcer Foot Ulcer Determined after the initial debridement Removal of callous and any necrotic material Probing of the ulcer

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12 Wagner Classification of Diabetic Foot Ulcers Grade I-superficial diabetic foot ulcer Grade II-ulcer extends into tendon,joint and or fascia Grade III-deep ulcer with abscess or osteomyelitis (probes to bone) Grade IV-gangrene to forefoot Grade V-extensive gangrene American Journal of Family Physicians. March,1998

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19 Evaluation of Diabetic Foot Ulcers Associated signs Erythema Edema Odor Drainage Crepitance Fluctuance

20 Evaluation of Diabetic Foot Ischemia Ulcer Temperature differences of the foot and leg

21 Evaluation of Diabetic Foot Ulcer Radiographic evaluation 2 view or 3 view plain xray MRI or CT 3 phase bone scan Tagged wbc/leukocyte scan Foreign body Fracture Osteomyelitis

22 Evaluation of Diabetic Foot Ulcer Radiographic evaluation Abscess/ gas Necrotizing fasciitis Foreign body

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24 Evaluation of Diabetic Foot Ulcer Deep wound cultures Vascular screening laboratory

25 Evaluation of Diabetic Foot Ulcer Vascular screening Transcutaneous oxygen measurement Ankle-Brachial index (ABI) Arterial ultrasound Venous evaluation for insuffiency or reflux angiography

26 Transcutaneous Oxygen Measurement

27 Ankle-Brachial Index

28 Evaluation of Diabetic Foot Ulcer Laboratory CBC CMP HgBA1C ESR CRP Wound cultures Blood cultures

29 Wound culture for Diabetic Foot Ulcer Ascertain culture after debridement Irrigate wound with saline prior to culture Culture deepest part of wound Do not touch wound edges or periwound

30 Diabetic Foot Infection

31 Antibiotics for Diabetic Foot Depends upon Ulcer Severity of infection Length of time the ulcer has been present Acute or chronic Previous antibiotics

32 Treatment of a Diabetic Foot Ulcer The best treatment is PREVENTION

33 Prevention of a Diabetic Foot Ulcer Frequent and routine evaluations Monofilament testing for neuropathy Noninvasive vascular studies Patient education

34 Patient Education for the prevention of a Diabetic Foot Foot hygiene Moisturize Ulcer No soaking of feet Nothing in between toes Mirror examination No heating pads or heat sources

35 Patient education for the prevention of a Diabetic Foot Nail care Ulcer Routinely by a podiatrist or other health care provider No clipping of the nails Ingrown toenails

36 Patient education for the prevention of a Diabetic Foot Ulcer Proper foot wear No bare feet Custom shoes Custom inserts

37 Treatment of a Diabetic Foot Ulcer Evaluation Antibiotics-topical is first line Antibiotics-oral for mild infection Antibiotics-IV for severe infection Daily ulcer care-keep ulcer covered and clean Offloading of the ulcer

38 Treatment of a Diabetic Foot Ulcer Edema control Vascular evaluation Frequent reevaluation

39 Referral for a Diabetic Foot Ulcer After initial evaluation If not healing or healed after 6 weeks Urgently if gangrene Abscess present

40 Pressure Ulcers Occurs in 5% of the patients in acute care facility 40-50% of patients in chronic care facilities develop pressure ulcers

41 Pressure Ulcers Etiology Occurs over any bony prominence Shear forces Friction forces Moisture Malnutrition Anemia Any Chronic Systemic illness

42 Pressure Ulcer Staging Stage 1 nonblanchable erythema intact skin may be painful, warm or cool identifies at risk patients

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44 Pressure Ulcer Staging Stage 2-partial thickness loss of dermis shallow ulcer no slough or eschar blister

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46 Pressure Ulcer Staging Stage 3-full thickness skin loss subcutaneous fat bone, tendon,muscle not exposed slough may be present tunneling and undermining

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48 Pressure Ulcer Staging Stage 4-full thickness tissue loss exposed bone,muscle,tendon slough present eschar present undermining tunneling

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50 Pressure Ulcer Staging Unstageable Full thickness tissue loss Depth obscured by slough and/or eschar

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52 Pressure Ulcer Staging Suspected Deep Tissue Injury Localized area of purple/maroon skin Blister Quickly evolves

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54 Pressure Ulcer Treatment Initial evaluation and staging Assess risk factors Laboratory Radiology Off loading/reduce pressure/shear/friction

55 Pressure Ulcer Treatment Culture the ulcer Acute ulcers Topical debridement Surgical debridement Bone biopsy

56 Off Loading of Pressure Ulcer Speciality mattress Low air loss Fluid air therapy Prone position Manual pressure relief

57 Surgical Treatment of Pressure Ulcer Debridement of infected tissue, slough and eschar Bone biospy Ostectomy Diverting colostomy Rotational muscle, fascial flaps Advancement muscle, fascial flaps Skin Grafts

58 When to refer a Pressure Ulcer Non healing after 6 weeks of conventional therapy Abscess Necrotizing fasciitis Acute osteomyelitis Gangrene

59 In Conclusion Diabetic foot ulcers and pressure ulcers are seen frequently by the primary care provider Adequate initial evaluation and treatment is important Referral to a specialist is appropriate after 6 weeks of treatment

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