History
The history should focus on the signs and symptoms of a diabetic foot ulcer or pre-ulcerative lesion. Symptoms indicative of possible peripheral neuropathy or peripheral arterial insufficiency should also be investigated.
In the diagnosis of diabetic foot ulcers or pre-ulcerative lesions, the following should be taken into account:
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History of trauma
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History of puncture wound (with or without shoe gear)
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History of change in shoe gear
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History of deformity, either acquired or congenital
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History of callus or blister
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History of wound care management
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History of offloading
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Local signs of infection
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Systemic signs of infection
Symptoms of peripheral neuropathy
The symptoms of peripheral neuropathy include the following:
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Hypoesthesia
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Hyperesthesia
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Paresthesia
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Dysesthesia
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Radicular pain
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Anhidrosis
Symptoms of peripheral arterial insufficiency
Most people harboring atherosclerotic disease of the lower extremities are asymptomatic; others develop ischemic symptoms. Some patients attribute ambulatory difficulties to old age and are unaware of the existence of a potentially correctible problem.
Patients who are symptomatic may present with intermittent claudication, ischemic pain at rest, nonhealing ulceration of the foot, or frank ischemia of the foot.
Cramping or fatigue of major muscle groups in one or both lower extremities that is reproducible upon walking a specific distance suggests intermittent claudication. This symptom increases with ambulation until walking is no longer possible, and it is relieved by resting for several minutes. The onset of claudication may occur sooner with more rapid walking or walking uphill or up stairs.
The claudication of infrainguinal occlusive disease typically involves the calf muscles. Discomfort, cramping, or weakness in the calves or feet is particularly common in the diabetic population because they tend to have tibioperoneal atherosclerotic occlusions. Calf muscle atrophy may also occur. Symptoms that occur in the buttocks or thighs suggest aortoiliac occlusive disease.
Rest pain is less common in the diabetic population. In some cases, a fissure, ulcer, or other break in the integrity of the skin envelope is the first sign that loss of perfusion has occurred. When a diabetic patient presents with gangrene, it is often the result of infection.
Physical Examination
Physical examination of the extremity that has a diabetic ulcer can be divided into different categories:
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Examination of ulceration
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Examination of the feet
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Assessment of the possibility of vascular insufficiency [4]
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Assessment for the possibility of peripheral neuropathy
Remember that diabetes is a systemic disease. Hence, a comprehensive physical examination of the entire patient is also vital.
Examination of ulceration
Accomplish the following in examination of ulceration
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Determine the location of the ulceration, as ulcers are typically located around bony prominences and weight-bearing surfaces; typical locations include the dorsal interphalangeal joints of hammertoes and distal tips of digits, below metatarsal heads in claw toes, the medial and lateral forefoot in patients with bunions and bunionettes, plantar lateral wounds in Charcot foot, and the lateral foot and lateral malleoli in varus deformities
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Measure the size, including the depth of the wound
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Describe the wound base (granular, fibrotic, necrotic, eschar)
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Inspect for probing to bone
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Inspect for any undermining or tunneling of the wound
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Describe any drainage
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Describe the periwound area (maceration, hyperkeratotic tissue)
Examination of feet
Carry out the following in foot examination [33] :
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Inspect the static posture of the feet on the examination table, as well as when weight-bearing.
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Assess for gross deformities and determine if they are reducible or rigid
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Assess ankle range of motion using the Silfverskiöld test - If there is limited ankle dorsiflexion (cannot pass neutral) with the knee both flexed and extended, it is considered gastrocsoleal tightness; if there is increased dorsiflexion with the knee flexed, however limited with the knee in extension, it is considered gastrocnemius equinus
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Assess range of motion at the interphalangeal joints, metatarsophalangeal joints, midtarsal joints, and subtalar joints
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Evaluate muscle power of dorsiflexors, plantar flexors, invertors, and evertors to identify any muscular imbalances
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Examine the skin for dryness and fissures, as well as for discrete calluses; hemorrhagic calluses in particular are a sign of impending foot ulceration.
Assessment of possible peripheral arterial insufficiency
Physical examination discloses absent or diminished peripheral pulses below a certain level.
Although diminished common femoral artery pulsation is characteristic of aortoiliac disease, infrainguinal disease alone is characterized by normal femoral pulses at the level of the inguinal ligament and diminished or absent pulses distally. Specifically, loss of the femoral pulse just below the inguinal ligament occurs with a proximal superficial femoral artery occlusion. Loss of the popliteal artery pulse suggests superficial femoral artery occlusion, typically in the adductor canal.
Loss of pedal pulses is characteristic of disease of the distal popliteal artery or its trifurcation. However, be aware that absence of the dorsalis pedis pulse may be a normal anatomic variant that is noted in about 10% of the pediatric population. On the other hand, the posterior tibial pulse is present in 99.8% of persons aged 0-19 years. Hence, absence of both pedal pulses is a more specific indicator of peripheral arterial disease.
Other findings suggestive of atherosclerotic disease include a bruit heard overlying the iliac or femoral arteries, skin atrophy, loss of pedal hair growth, cyanosis of the toes, ulceration or ischemic necrosis, and pallor of the involved foot followed by dependent rubor after 1-2 minutes of elevation above heart level.
Assessment of possible peripheral neuropathy
Signs of peripheral neuropathy include loss of vibratory and position sense, loss of deep tendon reflexes (especially loss of the ankle jerk), trophic ulceration, foot drop, muscle atrophy, and excessive callous formation, especially overlying pressure points such as the heel.
The nylon monofilament test helps diagnose the presence of sensory neuropathy. [34] A 10-gauge monofilament nylon is pressed against each specific site of the foot just enough to bend the wire. If the patient does not feel the wire at 4 or more of these 10 sites, the test is positive for neuropathy. General use filaments can be obtained from the National Institute of Diabetes and Digestive and Kidney Diseases, or the clinician can use professional Semmes-Weinstein filaments.
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Diabetic ulcer of the medial aspect of left first toe before and after appropriate wound care.
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Diabetic ulcer of left fourth toe associated with mild cellulitis.
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Charcot deformity with mal perforans ulcer of plantar midfoot.
Tables
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 débridement. |
These are useful for necrotic wounds as an adjunct to surgical débridement. |
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). |
Risk category |
Definition |
Suggested follow-up |
|---|---|---|
0 |
No LOPS, no PAD, no deformity |
Annually |
1 |
LOPS ± deformity |
Every 3–6 months |
2 |
PAD ± LOPS |
Every 2–3 months |
3 |
History of ulcer or amputation |
Every 1–2 months |
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- Overview
- Presentation
- DDx
- Workup
- Approach Considerations
- Blood Tests
- Plain Radiography
- Computed Tomography and Magnetic Resonance Imaging
- Bone Scans
- Ankle-Brachial Index
- Pulse-Volume Recording
- Ultrasonography
- Transcutaneous Tissue Oxygen Studies
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- Alternatives to Conventional Angiography
- Staging
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- Treatment
- Approach Considerations
- Management of Systemic and Local Factors
- Wound and Foot Care
- Surgical Care
- Options for Soft Tissue Coverage of the Clean but Nonhealing Wound
- Hyperbaric Oxygen Treatment
- Dietary Changes
- Restriction of Activity
- Measures for Prevention of Diabetic Ulcers
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