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Diabetic Ulcers Workup

  • Author: Vincent Lopez Rowe, MD; Chief Editor: Romesh Khardori, MD, PhD, FACP  more...
 
Updated: Jul 08, 2016
 

Approach Considerations

Patient workup for diabetic ulcers includes blood tests, pulse-volume recording, ultrasonography, ankle-brachial index, radiography, computed tomography, magnetic resonance imaging, bone scans, and angiography.

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Blood Tests

A complete blood count should be done. 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.[19]

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.

Blood testing should also include hemoglobin A1C assessment because a normal value is a surrogate marker for wound healing.[20]

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Pulse-Volume Recording

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.

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Ultrasonography

Duplex ultrasonography 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.

A handheld 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 (as in measurement of systolic pressure in extremity arteries).

Laser Doppler studies also have been used but may not be reliable.

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Ankle-Brachial Index

The systolic pressure in the dorsalis pedis or posterior artery 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, the ABI often is falsely elevated (and thus may be unreliable) if the underlying arteries are heavily calcified, a finding common in diabetic persons.

See recommendations for the workup of patients with atherosclerotic disease of the extremities in the Medscape Reference article Infrainguinal Occlusive Disease.

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Plain Radiography

Plain radiographic studies of the diabetic foot may demonstrate demineralization and Charcot joint and occasionally may suggest the presence of osteomyelitis. 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.

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Computed Tomography and Magnetic Resonance Imaging

Although an experienced clinician usually can diagnose a plantar abscess by physical examination alone, computed tomography (CT) scanning or magnetic resonance imaging (MRI) is indicated if a plantar abscess is suspected but not clear on physical examination.

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Bone Scans

Bone scans are of questionable use because of a sizable percentage of false-positive and false-negative results. A recent study suggests Technetium-99m-labeled ciprofloxacin is a somewhat useful marker for osteomyelitis.[21]

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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 interventionalist (interventional cardiologist, vascular surgeon, or interventional radiologist) may use an alternative entry point, such as via the brachial or axillary artery. 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. In most cases, the physician performing the angiogram may elect to use a small device to aid in closing the puncture site (“closure device”). Successful deployment of these devices eliminates the need for prolonged pressure application.

Puncture-related complications

Risks associated with catheter insertion include hemorrhage, pseudoaneurysm formation, and clotting or dislodgement of an intimal flap, which may acutely occlude the artery at or near the entry site. Use of percutaneous closure devices on the puncture sites has significantly reduced 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.[22]

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.

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Alternatives to Conventional Angiography

Magnetic resonance angiography

Magnetic resonance angiography (MRA) is an alternative 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. MRA is contraindicated in patients with implanted hardware such as a hip prostheses or pacemakers.

The resolution provided by MRA 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.[23]

Multidetector CT angiography

Multidetector CT (MDCT) angiography 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 angiography carries the contrast-related risks described above.[24]

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.

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Transcutaneous Tissue Oxygen Studies

Transcutaneous tissue oxygen studies are reserved for borderline situations in which the advisability of arterial bypass surgery may be unclear.

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Staging

Stage diabetic foot wounds based on the depth of soft tissue and osseous involvement.[4, 5, 6] 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.

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Contributor Information and Disclosures
Author

Vincent Lopez Rowe, MD Professor of Surgery, Program Director, Vascular Surgery Residency, Department of Surgery, Division of Vascular Surgery, Keck School of Medicine of the University of Southern California

Vincent Lopez Rowe, MD is a member of the following medical societies: American College of Surgeons, American Heart Association, Society for Vascular Surgery, Vascular and Endovascular Surgery Society, Society for Clinical Vascular Surgery, Pacific Coast Surgical Association, Western Vascular Society

Disclosure: Nothing to disclose.

Chief Editor

Romesh Khardori, MD, PhD, FACP Professor of Endocrinology, Director of Training Program, Division of Endocrinology, Diabetes and Metabolism, Strelitz Diabetes and Endocrine Disorders Institute, Department of Internal Medicine, Eastern Virginia Medical School

Romesh Khardori, MD, PhD, FACP is a member of the following medical societies: American Association of Clinical Endocrinologists, American College of Physicians, American Diabetes Association, Endocrine Society

Disclosure: Nothing to disclose.

Acknowledgements

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.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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Diabetic ulcer of the medial aspect of left first toe before and after appropriate wound care.
Diabetic ulcer of left fourth toe associated with mild cellulitis.
Charcot deformity with mal perforans ulcer of plantar midfoot.
Table. Characteristics and Uses of Wound Dressing Materials
Category Examples Description Applications
Alginate AlgiSite



Comfeel



Curasorb



Kaltogel



Kaltostat



Sorbsan



Tegagel



This seaweed extract contains guluronic and mannuronic acids that provide tensile strength and calcium and sodium alginates, which confer an absorptive capacity. Some of these can leave fibers in the wound if they are not thoroughly irrigated. These are secured with secondary coverage. These are highly absorbent and useful for wounds having copious exudate. Alginate rope is particularly useful to pack exudative wound cavities or sinus tracts.
Hydrofiber Aquacel



Aquacel-Ag



Versiva



An absorptive textile fiber pad, also available as a ribbon for packing of deep wounds. This material is covered with a secondary dressing. The hydrofiber combines with wound exudate to produce a hydrophilic gel. Aquacel-Ag contains 1.2% ionic silver that has strong antimicrobial properties against many organisms, including methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus. These are absorbent dressings used for exudative wounds.
Debriding agents Hypergel (hypertonic saline gel)



Santyl (collagenase)



Accuzyme (papain urea)



Various products provide some degree of chemical or enzymatic debridement. These are useful for necrotic wounds as an adjunct to surgical debridement.
Foam LYOfoam



Spyrosorb



Allevyn



Polyurethane foam has some absorptive capacity. These are useful for cleaning granulating wounds having minimal exudate.
Hydrocolloid Aquacel



CombiDERM



Comfeel



Duoderm CGF Extra Thin



Granuflex



Tegasorb



These are made of microgranular suspension of natural or synthetic polymers, such as gelatin or pectin, in an adhesive matrix. The granules change from a semihydrated state to a gel as the wound exudate is absorbed. They are useful for dry necrotic wounds, wounds having minimal exudate, and clean granulating wounds.
Hydrogel Aquasorb



Duoderm



IntraSite Gel



Granugel



Normlgel



Nu-Gel



Purilon Gel



(KY jelly)



These are water-based or glycerin-based semipermeable hydrophilic polymers; cooling properties may decrease wound pain. These gels can lose or absorb water depending upon the state of hydration of the wound. They are secured with secondary covering. These are useful for dry, sloughy, necrotic wounds (eschar).
Low-adherence dressing Mepore



Skintact



Release



These are various materials designed to remove easily without damaging underlying skin. These are useful for acute minor wounds, such as skin tears, or as a final dressing for chronic wounds that have nearly healed.
Transparent film OpSite



Skintact



Release



Tegaderm



Bioclusive



These are highly conformable acrylic adhesive film having no absorptive capacity and little hydrating ability, and they may be vapor permeable or perforated. These are useful for clean dry wounds having minimal exudate, and they also are used to secure an underlying absorptive material. They are used for protection of high-friction areas and areas that are difficult to bandage such as heels (also used to secure IV catheters).
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