Diabetic Foot Ulcer (Long Case)

History Taking:

C/C: Ulcer over the right or left foot.

HOPI:
A. Description of Ulcer
B. Stage of Ulcer (Wagener Classification)
C. Clinical Triad of DFU

Analysis of HOPI:
A. Description of Ulcer
1. Site
2. Number
3. Edge
4. Base
5. Bleeding
6. Pain sensation
7. Pathognomonic sign

B. Stage of Ulcer
- Stage 3: Pus discharge, Redness
- Stage 4: Blackish area on toe
- Stage 5: Blackish area of entire foot (Tx: below knee or above knee amputation)

C. Clinical Triad of DFU

1. Vasculopathy
2. Neuropathy
3. Immunopathy

1. Vasculopathy ● Vascular Claudication

- Pain
- Heaviness
- Weakness

2. Neuropathy ● Motor
- Toe deformity
- Weakness in Lower Limb
● Sensory
- Sensory deficit “Glove & Stoking Distribution”
 (ask patient is there any numbness in upper & lower limb)
● Autonomic
- History of Postural Hypotension

3. Immunopathy ● Infection
(ask patient is there any pus or discharge coming out from
wound)

Extra info:
2 types of Claudication
● Vascular Claudication
- Pain & heaviness start from distal to proximal.
- Walk for 5 minutes & feel pain.
● Spinal Claudication
- Pain & heaviness start from proximal to distal.
- Walk for 5 minutes & no pain.
Examination:
A. Describe Ulcer
I. Type of Ulcer (Ischemic, Neuropathic & Venous Ulcer)
Ischemic Ulcer Neuropathic Ulcer Venous Ulcer

1. Site Wound over the Wound over the Wound above

Dorsum Aspect Plantar Aspect Medial Malleolus

2. Number Multiple Single Single

3. Edge Vertical/ Edge raised higher than Slanted/ Healing Edge

Non-healing Edge skin level, hard over
plantar aspect
(Callosity)

4. Base Pale Pink Pink

- because blood vessels
- because blood vessels
intact.
compromised.

- use needle to poke the

base, no blood come out.

5. Bleeding No Yes Yes

- use needle to poke the - blood come out from
base, no blood come out. the base of ulcer.

6. Pain sensation Painful Painless Painful

7. Pathognomonic Callosity

II. Stage of Ulcer

Wagener Classification

Grade 0 No Ulcer but high-risk Foot

Grade 1 Superficial Ulcer

 Grade 2 Deep Ulcer, no infected

Grade 3 Deep Ulcer, infected

Grade 4 Localized gangrene e.g. toe, heel etc.

Grade 5 Extensive gangrene involving the whole foot.

B. Describe Foot

i. Forefoot
● Toe ● Capillary Refill Time < 2s
- In Normal person, CRT < 2s
- In Neuropathy, CRT < 2s
(because the ulcer is at plantar aspect)
- In Vasculopathy, CRT > 2s

● Nail ● Brittle Nail

- Autonomic nervous system problems
- Fungal infection in Immunocompromised patient like
Diabetes Mellitus

● Oximetry Sp02 ● Oximetry Sp02

- Sp02 < 80% (Vasculopathy)
- Sp02 > 80% (Vessels intact)

● Tuft of hair ● Tuft of hair at base of big toe

- Loss of hair distribution over big toe due to autonomic
nervous system problems.

● Small Toe ● 4 common deformities of small toe

(due to Motor Neuropathy)

- Hyperextend MTP
- Flexed PIP
- Hyperextend DIP
 - Hyperextend MTP
- Hyperextend PIP
- Flex DIP

- Flex MTP
- Flex PIP
- Flex DIP

- Hyperextend MTP
- Flex PIP
- Flex DIP

ii. Midfoot
● Skin Condition - Any dry, shinny, swollen, loss of hair distribution
(autonomic nervous system problem in case of
neuropathy)

● Dorsalis Pedis Artery Aim: Look for vasculopathy.

Method:

- stand between the foot

- Use 3 fingers to feel simultaneously & compare left

& right side.

- Feel for volume.

(In vasculopathy, the volume is no equal)

● Transcutaneous Oxygen Tension
Aim: Measuring the local oxygen tension in the skin
deriving from the local capillary blood perfusion.
- predicts wound healing potential
- helps define degree of small vessel disease
- accurately determine amputation level
- monitors efficacy of patient ongoing therapy
- establishes candidacy for HBO treatment

Reference Values for tcp02:

 ● > 40 mmHg: normal
● < 40 mmHg: vasculopathy

iii. Hindfoot
● Medial Malleolus - Put a 128Hz Tuning Fork on Medial Malleolus test for
(Tuning fork Test) vibration sensation.
- Tuning Fork Test negative = Sensory Neuropathy in
Neuropathic Ulcer.

● Posterior Tibialis Artery - Check for pulse at the Posterior Tibialis Artery.
(Compare both side and see whether the volume is
reduced or not)

iv. Plantar
● Semmes Weinstein 10 points of sensation in the foot for monofilament test
monofilament test
(9 points in the plantar + 1 point at the dorsum)

Plantar aspect:

1. Big Toe
2. 3rd Toe
3. 5th Toe
4. Ball of Big Toe
5. Ball of 3rd Toe
6. Ball of 5th Toe
7. Medial
8. Lateral
9. Heel
 Dorsum aspect:

10. Web space between Big toe and 2nd toe

● Foot Elevation Test - If plantar aspect of patient’s leg is Hyperemia (red color),
the cause can be due to Autonomic problem or Cellulitis.

How to differentiate between Autonomic problem or

Cellulitis?

Foot Elevation Test

(differentiate whether the hyperemia due to autonomic
problem or cellulitis)
Method:

- Put a pillow under patient’s leg and keep elevated for 2

minutes.

- If color disappear after 2 minutes, Autonomic problems

- If color persist after 2 minutes, Infection (DFU grade 3)

● Take Note: NO NEED to feel for Local Temperature in DFU case because you are wearing glove and will
spread infection when you touch the wound.