Diabetic Ulcer

Prevention

  • Education
    • Glycemic control
    • BP/LDL
    • Smoking
    • Activity/trauma
    • Footwear
    • Foot are (skin, nail care routine)
  • Annual foot exam
    • Skin, structure (Charcot, clawtoe, hammertoe)
    • Vascular (pulses/temperature)
    • Footwear
      • Toe box should fit toes
      • Cushioning
    • r/o neuropathy
      • Monofilament test
  • Therapeutic footwear/orthotics

Assess

  • Ischemia
    • ABI
      • Ankle/pedal doppler arterial waveforms
      • Toe systolic pressure or TcPO2
  • Infection
  • Neuropathy

Management

Wound care

  • Debridement q1-4w
    • Debris (biofilm)
    • Eschar/Devitalized tissue
    • Surrounding callus
  • Moisture balance
    • Moist wound bed, control exudate, avoid maceration
  • Bacterial balance
    • Topical vs. oral vs. IV antibiotics
  • Consider negative pressure wound therapy if no healing despite 4-8 weeks of therapy

Offloading

  • Relieve pressure
    • Total contact cast
    • Removable cast walker (can be rendered irremovable with tape)

PAD

  • Vascular consultation
    • Revascularization

Osteomyelitis

  • Suspect
    • Large ulcer >2cm^2
    • Deep ulcer >3mm
    • Probe-to-bone test
      • Serial X-ray
      • CRP>70 / ESR
    • If suspected osteomyelitis
      • CT vs. MRI vs. Bone Scan
      • Antibiotics
        • >4-6 weeks if no bone debridement
      • Orthopedics consultation
        • Bone debridement, biopsy, culture