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Foot ulcer
A standardized and consistent strategy of evaluating wounds is essential and will guide further therapy. The following items must be addressed:
The cause of ulcer
Ill-fitting shoes are the most frequent cause of an ulcer, even in patienst with "pure" ischemic ulcers. Therefore, the shoes should be examined meticulously in all patients.
The type of ulcer
Most ulcers can be classified as neuropathic, ischemic or neuro-ischemic. This will guide further therapy. Assessment of the vascular tree is essential in the management of a foot ulcer.
If pedal pulses are absent and/or the ankle brachial index is <0.9, or if an ulcer does not improve despite optimal treatment, more extensive vascular evaluation should be performed. If a major amputation is under consideration, the option of revascularization should be considered first. Measurement of the ankle pressure is the most widely used method to diagnose and quantify peripheral vascular disease. However, ankle pressures may be falsely elevated due to calcification of the arteries.
Alternative methods are compared in figure 5.
Fig 5. A schematic estimate of the probability of healing of foot ulcers and minor amputations in relation to
ankle blood pressure, toe blood pressure and transcutaneous oxygen pressure (TcPo2) based on selected reports.
The site and depth
Neuropathic ulcers frequently occur on the plantar surface of the foot, or in areas overlying a bony deformity. Ischemic and neuro-ischemic ulcers are more common on the tips of the toes or the lateral border of the foot.
The depth of an ulcer can be difficult to determine due to the presence of overlying callus or necrosis. Therefore, neuropathic ulcers with callus and necrosis should be debrided as soon as possible. This debridement should not be performed in ischemic or neuro-ischemic ulcers without signs of infection. In neuropathic ulcers the debridement can usually be performed without (general) anesthesia.
Signs of infection
Infection in a diabetic foot presents a direct threat to the involved limb and should be treated promptly and aggressively. Signs and/or symptoms of infection, such as fever, pain or increased white blood count/ESR, are often absent. But, if present, substantial tissue damage or even development of an abscess is likely.
The risk of osteomyelitis should be determined. If it is possible to place a probe down to the bone before initial debridement, there is an increased risk of the presence osteomyelitis.
A superficial infection is usually caused by Gram-positive bacteria. In cases of (possible) deep infections Gram stains and cultures from the deepest tissue involved are advised (no superficial swabs); these infections are usually polymicrobial, involving anaerobes and Gram positive/negative bacteria.
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