DIABETIC (NEUROPATHIC) ULCERS Although white-cell scans are sensi

Ulceration is caused by several factors acting together, but resonance imaging (MRI) is now co
particularly by neuropathathy. Peripheral neuropathy results in loss of when osteomyelitis is suspected; th
the protective sensation of pain and in autonomic dysfunction, with osteomyelitis in diabetic patients ar
sympathetic denervation, dry skin, and warm feet. management
Other important component causes of ulceration include peripheral The principles of management of ne
vascular disease,callus, edema, and deformity. The triad of infection and removal of pressure fr
neuropathy, deformity, and trauma is General Care
present in almost two thirds of patients with foot ulcers. 1-Glycemic control is important, sin
Diagnosis patients with chronic hyperglycemi
History 2-Patients should be advised to stop
Information relating to ulcer history should factors, but also because smokers h
be recorded in a structured format and may infections than nonsmokers or form
include 3-Do not go bearfoot- well fitting sh
• year first ulcer occurred between the toes
• site of ulcer and of any previous ulcers 4-Keep the feet clean and dry
• number of previous episodes of 5- Seek help trim toenails, or if corn
ulceration 6-Comply with medications
• time to healing in previous episodes 7- Avoid exposure to cold, friction,
• time free of ulcers 8•-Aviod use of external heat (heat
• past treatment methods Wound Management
(both successful and unsuccessful) 1.Sharp débridement-the removal o
• previous operations on venous system tissue as well as foreign and infecte
• previous and current use of compression the wound
.Interrmittent claudication, varices, lack of sensation,pain 2. Treatment of local edema. Interm
Family hx of DM,HTN pump results in a higher rate of hea
Features of ischemic heart dz,retinopathy,nephropathy 3. Removal of Pressure-reducing m
Techniques for removing pressure i
Ulcer Assessment shoes, sandals, and felted foam dres
If the ulcer has been present for months and is asymptomatic and if non removable cast) over the involv
foot pulses are palpable,neuropathy should be considered as a major to standard therapy and other techni
cause. Contraindications to total contact ca
However, given the variability of assessment of foot pulses, infected or ischemic wounds.
noninvasive assessment of the peripheral circulation is recommended 4. Dressings-The development of dr
if there is any suggestion of peripheral ischemia. environment to assist healing has be
Callus formation and a plantar site of ulceration also suggest The selection of a dressing involves
neuropathy as a major contributory cause. A combination of lack of (such as control of exudates) with th
sensation, limited joint mobility, autonomic dysfunction resulting in patient.
dry skin, and repetitive high pressure may lead to callus formation. 5.Infection control
The relative risk of ulcer development at an area of high pressure The choice of antibiotic for infected
(i.e., the metatarsal heads, as compared with the mid-foot) is and that is initially based on the pathogens p
of an ulcer developing at a site of callus present. Commonly used broad-spe
Vascular status must be assessed pulses, parlour, parasthesia, pain, include clindamycin, cephalexin, ci
temperature and amoxicillin–clavulanic acid (Au
Intravenous antibiotic options for m
Investigations (e.g., cellulitis) include imipenem, (
Pulses and piperacillin–tazobactam), and b
BP cephalosporins
Random blood sugar Soft-tissue infections usually requir
Doppler Ultrasound osteomyelitis may require more tha
Arteriogram accompanied by surgical débrideme
Swab wound for microscopy, cultur
Infection of the Ulcer
Infection is usually a consequence, rather than a
cause, of ulceration, which allows the entry and
multiplication of microorganisms.
A commonly accepted definition of foot infection is the presence of
systemic signs of infection (e.g., fever, leukocytosis ) or purulent
secretions, or two or more local symptoms or signs (redness, warmth,
induration, pain, or
tenderness).
Since foot infection has the potential to threaten the limb, appropriate
diagnosis and therapy are urgently required. If infection is present, a
deep-tissue specimen should be obtained aseptically, if possible; such
specimens are superior to superficial swab specimens for the isolation
of resistant organisms.
Polymicrobial isolates, including aerobic and anaerobic species, are
common.

Osteomylltis
The findings on plain radiographs are often
suggestive of osteomyelitis (manifested as bone
destruction or periosteal reaction, especially as compared
with findings on prior films) and radiographs
are therefore recommended by many experts when
there is evidence of infection.
Histologic evaluation and culture of a bone-biopsy specimen are
regarded as the gold standard
.