Diabetic Foot Ulcers
- Diabetics are prone to foot ulcerations due to both
neurologic and vascular complications.
- Peripheral neuropathy can cause altered or complete loss
of sensation in the foot and /or leg. Similar to the
feeling of a "fat lip" after a dentist's
anesthetic injection, the diabetic with advanced
neuropathy looses all sharp-dull discrimination. Any cuts
or trauma to the foot can go completely unnoticed for
days or weeks in a patient with neuropathy. It's not
uncommon to have a patient with neuropathy tell you that
the ulcer "just appeared" when, in fact, the
ulcer has been present for quite some time. There is no
known cure for neuropathy, but strict glucose control has
been shown to slow the progression of the neuropathy.
- Charcot foot deformity occurs as a result of decreased
sensation. People with "normal" feeling in
their feet automatically determine when too much pressure
is being placed on an area of the foot. Once identified,
our bodies instinctively shift position to relieve this
stress. A patient with advanced neuropathy looses this
important mechanism. As a result, tissue ischemia and
necrosis may occur leading to plantar ulcerations.
Microfractures in the bones of the foot go unnoticed and
untreated, resulting in disfigurement, chronic swelling
and additional bony prominences.
- Microvascular disease is a significant problem for
diabetics and can lead to ulcerations. It is well known
that diabetes is called a small vessel disease. Most of
the problems caused by narrowing of the small arteries
cannot be resolved surgically. It is critical that
diabetics maintain close control on their glucose level,
maintain a good body weight and avoid smoking in an
attempt to reduce the onset of small vessel disease.
- Treatment: First, you must determine the cause of
this ulcer. Is it neuropathic, ischemic or a combination?
Base your treatment protocol on the etiology of the
ulcer. Assuming that there is adequate perfusion to heal
a plantar ulcer, one should have appropriate shoe
modifications made to disperse weight away from the
ulcerative area. Absorb any excess discharge and maintain
a moist wound environment with appropriate product
selection. Keep the wound edges dry. Make sure no sinus
tracking occurs. Watch for infection. Debride necrotic
debris and the hyperkeratotic rim as they are niduses of
for infection.
Case Study: This patient is an insulin dependent diabetic who
presented with the above ulcer. The lesion was present for almost
3 years. Treatment consisted of wound cleansing, aseptic surgical
debridement, application of castellani's paint to the wound
edges, a hydrogel to the wound base covered by Allevyn foam
dressing. Molded shoes with a plastizote insert were also
obtained.
Authored by Dr. Tamara D. Fishman.
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