Diabetic Foot Ulcers and Pressure Ulcers Laurie Duckett D.O. Plastic and Reconstructive Surgeon Oklahoma State University Center for Health Sciences
Lecture Objectives Identify risk factors Initiate appropriate evaluation and work up Treatment Referral
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
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
Evaluation of a Diabetic Foot Ulcer History progression of the ulcer etiology of the ulcer previous ulceration
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
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
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
Evaluation of Diabetic Foot Ulcers Associated signs Erythema Edema Odor Drainage Crepitance Fluctuance
Evaluation of Diabetic Foot Ischemia Ulcer Temperature differences of the foot and leg
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
Evaluation of Diabetic Foot Ulcer Radiographic evaluation Abscess/ gas Necrotizing fasciitis Foreign body
Evaluation of Diabetic Foot Ulcer Deep wound cultures Vascular screening laboratory
Evaluation of Diabetic Foot Ulcer Vascular screening Transcutaneous oxygen measurement Ankle-Brachial index (ABI) Arterial ultrasound Venous evaluation for insuffiency or reflux angiography
Transcutaneous Oxygen Measurement
Ankle-Brachial Index
Evaluation of Diabetic Foot Ulcer Laboratory CBC CMP HgBA1C ESR CRP Wound cultures Blood cultures
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
Diabetic Foot Infection
Antibiotics for Diabetic Foot Depends upon Ulcer Severity of infection Length of time the ulcer has been present Acute or chronic Previous antibiotics
Treatment of a Diabetic Foot Ulcer The best treatment is PREVENTION
Prevention of a Diabetic Foot Ulcer Frequent and routine evaluations Monofilament testing for neuropathy Noninvasive vascular studies Patient education
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
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
Patient education for the prevention of a Diabetic Foot Ulcer Proper foot wear No bare feet Custom shoes Custom inserts
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
Treatment of a Diabetic Foot Ulcer Edema control Vascular evaluation Frequent reevaluation
Referral for a Diabetic Foot Ulcer After initial evaluation If not healing or healed after 6 weeks Urgently if gangrene Abscess present
Pressure Ulcers Occurs in 5% of the patients in acute care facility 40-50% of patients in chronic care facilities develop pressure ulcers
Pressure Ulcers Etiology Occurs over any bony prominence Shear forces Friction forces Moisture Malnutrition Anemia Any Chronic Systemic illness
Pressure Ulcer Staging Stage 1 nonblanchable erythema intact skin may be painful, warm or cool identifies at risk patients
Pressure Ulcer Staging Stage 2-partial thickness loss of dermis shallow ulcer no slough or eschar blister
Pressure Ulcer Staging Stage 3-full thickness skin loss subcutaneous fat bone, tendon,muscle not exposed slough may be present tunneling and undermining
Pressure Ulcer Staging Stage 4-full thickness tissue loss exposed bone,muscle,tendon slough present eschar present undermining tunneling
Pressure Ulcer Staging Unstageable Full thickness tissue loss Depth obscured by slough and/or eschar
Pressure Ulcer Staging Suspected Deep Tissue Injury Localized area of purple/maroon skin Blister Quickly evolves
Pressure Ulcer Treatment Initial evaluation and staging Assess risk factors Laboratory Radiology Off loading/reduce pressure/shear/friction
Pressure Ulcer Treatment Culture the ulcer Acute ulcers Topical debridement Surgical debridement Bone biopsy
Off Loading of Pressure Ulcer Speciality mattress Low air loss Fluid air therapy Prone position Manual pressure relief
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
When to refer a Pressure Ulcer Non healing after 6 weeks of conventional therapy Abscess Necrotizing fasciitis Acute osteomyelitis Gangrene
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