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Diabetic Ulcers: Differential Diagnoses & Workup

Author: Richard M Stillman, MD, FACS, Honorary Medical Staff, Northwest Medical Center; Former Chief of Staff and Medical Director, Wound Healing Center, Department of Surgery, Northwest Medical Center
Contributor Information and Disclosures

Updated: Oct 28, 2009

Differential Diagnoses

Atherosclerosis
Chronic Venous Insufficiency
Diabetic Foot Infections

Other Problems to Be Considered

The classic diabetic trophic ulcer must be distinguished from various other problems that tend to occur in persons with diabetes, such as diabetic dermopathy, bullosis diabeticorum, eruptive xanthoma, necrobiosis lipoidica, and granuloma annulare.

The leg pain of peripheral arterial disease must be distinguished from other causes of leg pain, such as arthritis, muscle pain, radicular pain, spinal cord compression, thrombophlebitis, anemia, and myxedema.

Diabetic neuropathy should be distinguished from other forms of neuropathy, including vasculitic neuropathies, metabolic neuropathies, autonomic neuropathy, radiculopathy, and many others.

Workup

Laboratory Studies

  • CBC count: Leukocytosis may signal plantar abscess or other associated infection. Wound healing is impaired by anemia. In the face of underlying arterial insufficiency, anemia may precipitate rest pain.11
  • Metabolic profile and glycohemoglobin: Assessment of serum glucose, glycohemoglobin, and creatinine levels helps to determine the adequacy of acute and chronic glycemic control and the status of renal function.
  • Noninvasive vascular laboratory study: Pulse-volume recording (PVR), or plethysmography, uses pneumatic cuffs encircling the thighs, calves, ankles, feet, and, occasionally, toes to sense segmental volume changes with each pulse beat. The resulting tracings provide useful information about the hemodynamic effects of the arterial disease at each level. In severe disease, tracings at the transmetatarsal level may become nearly flat. In mild disease, particularly involving the aortoiliac segment, PVR tracings may appear normal at rest and become abnormal only after the patient walks until symptoms occur. PVR is noninvasive and rapid and, therefore, may be repeated frequently to help assess the overall hemodynamic response to medical or surgical treatment. Ordinarily, if pedal pulses are satisfactory, arterial evaluation PVR provides no useful information.
  • The ankle-brachial blood pressure index is potentially unreliable because of arterial calcification.
  • See recommendations for the workup of patients with atherosclerotic disease of the extremities in the eMedicine article Infrainguinal Occlusive Disease.

Imaging Studies

  • Duplex scanning can provide images of arterial segments that help localize the extent of disease, and simultaneous Doppler measurement of flow velocity can help estimate the degree of stenosis. Duplex scanning is quite useful in visualizing aneurysms, particularly of the aorta or popliteal segments. Use of this technique probably is best left to the discretion of the vascular specialist.
  • Plain radiograph studies of the diabetic foot may demonstrate demineralization and Charcot joint and occasionally may suggest the presence of osteomyelitis. Note that plain radiograph studies have no role in the evaluation of arterial disease. This is because arterial calcification observed on plain radiographs is not a specific indicator of severe atherosclerotic disease. Calcification of the arterial media is not diagnostic of atherosclerosis, and even calcification of the arterial intima, which is diagnostic of atherosclerotic disease, does not necessarily imply hemodynamically significant stenosis.
  • CT scan and MRI: Although an experienced clinician usually can diagnose a plantar abscess by physical examination alone, CT scan or MRI is indicated if a plantar abscess is suspected but not clear on physical examination.
  • Bone scans are of questionable use because of a sizable percentage of false-positive and false-negative results. A recent study suggests 99mTc-labeled ciprofloxacin is a somewhat useful marker for osteomyelitis.12
  • Conventional Angiography: If vascular or endovascular surgical treatment is contemplated, angiography is needed to delineate the extent and significance of atherosclerotic disease. Major risks associated with conventional contrast-injection angiography are related to the puncture and to the use of contrast agents. See also Infrainguinal Occlusive Disease.
    • Technique: Typically, a catheter is inserted retrograde via a femoral puncture, and contrast is power-injected into the infrarenal aorta. Films are taken as the contrast is followed down to both feet. In certain cases, as with aortic occlusion, a femoral approach to the aorta may not be possible. In this case, the radiologist may use an alternate entry such as via an axillary artery or even directly into the infrarenal aorta via a translumbar approach.
    • Puncture-related complications: The arterial catheter is usually passed through a 5F sheath that is 1.6 mm in diameter. This is a sizable hole in the femoral artery, which may be only 6-10 mm in diameter. After the catheter is removed, gentle pressure must be applied to the puncture site for approximately 30 minutes, and the radiologist must balance the need for hemostasis against the possibility of arterial occlusion. Risks include hemorrhage, pseudoaneurysm formation, and clotting or dislodgement of an intimal flap, which may acutely occlude the artery at or near the entry site. Currently, newer methods of percutaneous closure of the puncture sites have significantly reduced the site complication rates.
    • Contrast-related risks: Angiographic contrast material is nephrotoxic. The risk of precipitating acute renal failure is highest in patients with underlying renal insufficiency and those with diabetes. Patients with both of these risk factors have a 30% rate of acute renal failure following contrast angiography. Hence, an acceptable serum creatinine level must be confirmed prior to elective angiography. Avoid contrast angiography (if possible) for patients with any significant degree of renal impairment. If contrast angiography is absolutely required despite renal impairment, use a minimal volume of contrast material. In addition, providing adequate hydration prior to, during, and after the procedure is essential. Oral administration of the antioxidant acetylcysteine (Mucomyst) the night prior to and then just before angiography may be protective of renal function for patients at risk of contrast-induced nephropathy.13
    • Metformin warning: To prevent the possibility of fatal lactic acidosis, patients with diabetes who are taking metformin (Glucophage) must not take this medication immediately following contrast angiography. Patients may resume taking the medication when normal renal function is confirmed 1-2 days after contrast exposure.
  • Alternatives to conventional angiography
    • Magnetic resonance angiography: Magnetic resonance angiography (MRA) is an alternative both for patients for patients who are allergic to iodinated contrast material. MRA is not innocuous. Gadolinium chelates, the contrast agents used in MRA, have been linked recently to 3 potentially serious side effects in patients with renal insufficiency: acute renal injury, pseudohypocalcemia, and nephrogenic systemic fibrosis (see this article on Medscape). MRA is contraindicated in patients with implanted hardware such as a hip prostheses or pacemakers. The resolution may be inadequate for the vascular surgeon in planning reconstructive procedures, particularly in the smaller infrapopliteal arteries, although MRA technology and contrast agents continue to improve.14
    • Multidetector computed tomographic angiography (MDCT): MDCT avoids arterial puncture. By using precisely timed intravenous contrast injection, multidetector (16 or 64 channel) CT scanners can generate angiographic images of excellent resolution and at a relatively high acquisition speed. MDCT carries the contrast-related risks described above.15
    • Carbon dioxide angiography: Carbon dioxide angiography is an alternative for patients with renal insufficiency; however, it is not widely available and requires some iodinated contrast material in addition to the carbon dioxide gas in order to provide useful images.
    • Plain radiography: Plain radiographs are not routinely obtained in the workup of peripheral arterial occlusive disease. This is because arterial calcification seen on plain radiographs is not a specific indicator of severe atherosclerotic disease. Calcification of the arterial media is not diagnostic of atherosclerosis, and even calcification of the arterial intima, which is diagnostic of atherosclerotic disease, does not necessarily imply hemodynamically significant stenosis.

Other Tests

  • A hand-held Doppler scanner may be used to assess arterial signals, to localize arteries to facilitate palpation of pulses, or to determine the loss of Doppler signal as a proximal blood pressure cuff is inflated. The latter pressure divided by the upper extremity systolic pressure is called the ankle-brachial index (ABI) and is an indication of severity of arterial compromise. Normal ABI averages 1.0. An ABI less than 0.9 suggests atherosclerotic disease, with a sensitivity of approximately 95%. In general, an ABI below 0.3 suggests a poor chance for healing of distal ischemic ulcerations. Unfortunately, ABI often is falsely elevated if the underlying arteries are heavily calcified, a finding common in diabetic persons.
  • Transcutaneous tissue oxygen studies are reserved for borderline situations in which the advisability of arterial bypass surgery may be unclear.
  • Laser Doppler studies also have been used but may not be reliable.

Staging

Stage diabetic foot wounds based on the depth of soft tissue and osseous involvement.16,17,18 Any ulcer that seems to track into or is deep to the subcutaneous tissues should be probed gently, and, if bone is encountered, osteomyelitis is likely.

More on Diabetic Ulcers

Overview: Diabetic Ulcers
Differential Diagnoses & Workup: Diabetic Ulcers
Treatment & Medication: Diabetic Ulcers
Follow-up: Diabetic Ulcers
Multimedia: Diabetic Ulcers
References
Further Reading
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References

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Further Reading

Clinical guidelines

Wound, Ostomy, and Continence Nurses Society (WOCN). Guideline for management of wounds in patients with lower-extremity neuropathic disease. Glenview (IL): Wound, Ostomy, and Continence Nurses Society (WOCN); 2004. 57 p. (WOCN clinical practice guideline; no. 3).

National Collaborating Centre for Primary Care. Clinical guidelines for type 2 diabetes. Prevention and management of foot problems. London (UK): National Institute for Clinical Excellence (NICE); 2004 Jun. 104 p.

Lipsky BA, Berendt AR, Deery HG, Embil JM, Joseph WS, Karchmer AW, Lefrock JL, Lew DP, Mader JT, Norden C, Tan JS. Diagnosis and treatment of diabetic foot infections. Clin Infect Dis 2004 Oct 1;39(7):885-910. 47

Registered Nurses Association of Ontario (RNAO). Assessment and management of foot ulcers for people with diabetes. Toronto (ON): Registered Nurses Association of Ontario (RNAO); 2005 Mar. 112 p.

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Keywords

diabetes, ulcers, diabetic ulcers, diabetic dermal ulcer, diabetic dermal wound, diabetic foot wound, diabetic neuropathic ulceration, intractable plantar wound, neuropathic ulceration, neuropathic wound, silver dressings

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Contributor Information and Disclosures

Author

Richard M Stillman, MD, FACS, Honorary Medical Staff, Northwest Medical Center; Former Chief of Staff and Medical Director, Wound Healing Center, Department of Surgery, Northwest Medical Center
Richard M Stillman, MD, FACS is a member of the following medical societies: American College of Angiology, American College of Surgeons, Association for Academic Surgery, and Society of University Surgeons
Disclosure: Nothing to disclose.

Medical Editor

Jeffrey Lawrence Kaufman, MD, Associate Professor, Department of Surgery, Division of Vascular Surgery, Tufts University School of Medicine
Jeffrey Lawrence Kaufman, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Society for Artificial Internal Organs, Association for Academic Surgery, Association for Surgical Education, Massachusetts Medical Society, Phi Beta Kappa, and Society for Vascular Surgery
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Vincent Lopez Rowe, MD, Assistant Professor of Surgery, Department of Surgery, Division of Vascular Surgery, University of Southern California Medical Center
Vincent Lopez Rowe, MD is a member of the following medical societies: American College of Surgeons, Association for Academic Surgery, Peripheral Vascular Surgery Society, Society for Clinical Vascular Surgery, and Society for Vascular Surgery
Disclosure: Nothing to disclose.

CME Editor

Paolo Zamboni, MD, Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy
Paolo Zamboni, MD is a member of the following medical societies: American Venous Forum and New York Academy of Sciences
Disclosure: Nothing to disclose.

Chief Editor

William H Pearce, MD, Chief, Division of Vascular Surgery, Violet and Charles Baldwin Professor of Vascular Surgery, Department of Surgery, Northwestern University School of Medicine
William H Pearce, MD is a member of the following medical societies: American College of Surgeons, American Heart Association, American Surgical Association, Association for Academic Surgery, Association of VA Surgeons, Central Surgical Association, New York Academy of Sciences, Society for Vascular Surgery, Society of Critical Care Medicine, Society of University Surgeons, and Western Surgical Association
Disclosure: Nothing to disclose.

 
 
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