Diabetic

Foot Ulcers

Prevention & Management

 Epidemiology
15-20 % of diabetic develop ulcers
85% of lower extremity amputations proceeded
by foot ulcers
50% reoccurance with in 18 months
205 of all diabetic people who enter the
hospital do so because of foot problems
Major source of morbidity. Mortality,
prolonged hospital stays & high medical
expenses
 AMPUTATIONS
Infected non-healing ulcers – major cause

every year 1/250 diabetics

undergo amputation of
part of the lower extremity

5-15% of diabetics require

amputation some time
in their life
50% of these amputees develop infected ulcers on the
contra lateral limb within 18 months and amputation
with in 3-5 years

50% mortality 3 years after 1st amputation

with in 5 years of plantar ulcer development the
cumulative reoccurance rate of ulceration is 70% and
amputation rate is 12%

Almost 50% of all amputations

were preventable
 Diabetic Foot Ulcers
Risk Factors for Ulceration
Neuropathy -- 60-70%
or
Arterial PVD --15-20%
or
Combination of
Neuropathy & PVD --15-20%
&
Trauma

Greater # of risk factors = greater risk of ulceration

 Uncontrolled Hyperglycemia

Decrease Hyperglycemia

Decrease/Delay Complications
 Neuropathy
• Affects 50% of people who have been
diabetic for 25 years

Types

SENSORY

MOTOR
Toe ulcer in a diabetic patient
AUTONOMIC with neuropathy
 Diabetic Peripheral Neuropathy
Nerve damage in the feet can result in a loss of foot
sensation, increasing your risk of foot problems.
Injuries and sores on the feet may
go unrecognised

Practice proper skin and foot care.

Rarely, other areas of the body such as the arms,

abdomen, and back may be affected.
 Symptoms of diabetic peripheral
neuropathy
Tingling
Numbness (severe or long-
term numbness can become
permanent)
Burning (especially in the evening)
Pain

In most cases, early symptoms will become less

troublesome when blood glucose is under
control.
 Prevent the complications of peripheral
neuropathy

Examine your feet and legs daily

Care for your nails regularly. (Go to a

podiatrist, if necessary)

Wear properly fitting footwear and wear them

all the time to prevent foot injury
 Peripheral Sensory Neuropathy
Loss of Protective Sensation

• Breakdown over weight bearing surfaces of feet

• Major risk for ulceration & amputation
• Ulceration most often due to “repetitive
moderate stress” from footwear
• Tissue damage-walking bare foot - chemical
injury (corn plasters) /thermal injury
• Very amenable to treatment with risk lowering
measures
People with neuropathy
can walk on pins,
sharp glass, poorly
fitting shoes etc.
without being aware of
it.
 Sensory Neuropathy
Patients usually unaware

Detection by clinician

LEAP Program:
Education and Free Monofilaments
www.bphc.hrsa.gov/leap/

Neurosensory Testing:
Semmes-Weinstein 5.07 Monofilament
 Motor Neuropathy
Assessment
Absence of Achilles Tendon & ankle
reflex

Treatment
prophylactic surgery
shoe with a larger toe box
in-depth shoe with cushioned
insole
 Motor Neuropathy
Charcot Foot:
rare and serious complication
occurs in less then 1% of diabetics
usually in the 5th or 6th decade in insulin
dependent diabetics

duration of diabetes usually greater then 12 years

Usually unilateral – 20% bilateral

 Charcot Foot
Multiple micro fractures

progressive destruction of bone-joint complex bony

protrusion & insensate foot – pressure induced
ulceration under foot deformity

Often present acutely with warmth, pain and swelling

Acute CF – non-weight bearing
 Charcot Foot

Results in thinner muscle and

fat pads

May have rocker bottom contour

to the foot – with maximum
weight bearing on mid portion of
plantar surface
 Motor Neuropathy

Limited joint mobility

Decreased range of motion at the ankles,

large toe, and other joints in the foot

Increases pressure on the plantar surface

 Motor Neuropathy
Damage to the intrinsic musculature of the foot

Hammer Toes
Toes “curled up”- claw like
Fat pads on plantar surface pushed upwards
proximally
Metatarsal heads become more prominent on
plantar surface
Increased pressure at the tops and tips of the
toes and under the first metatarsal head
 ME TAR SAL H EAD
PROMINE NCE AND UL CERA TION

peripheral neuropathy & ulceration over the

plantar surface of the metatarsal heads
 Autonomic Neuropathy
Absence of sweating, resulting in dry,
cracked skin
Neuropathic Ulcer
Characteristics
surrounded by thick
hyperkeratosis
pink, punched out base - bleeds fairly
easily
painless
foot warm with palpable pulses

location associated with

pressure
 Other Neurological
complications
Diabetic Proximal Neuropathy
Diabetic proximal neuropathy causes pain
(usually on one side) in the thighs, hips,
or buttocks.

Weakness in the legs.

Provided by MedicineNet.com with Cleavland Clinic

 Neurological
complications
Treatment for weakness or pain is usually
needed

May include:
medication and physical therapy
Recovery varies, depending on the type of
nerve damage.
Prevention consists of keeping blood
glucose under tight control.
Provided by MedicineNet.com with Cleavland Clinic
 Diabetic Focal Neuropathy

Diabetic neuropathy can also

appear suddenly and affect specific
nerves, most often in the head,
torso, or leg, causing muscle
weakness or pain. This is known as
focal neuropathy.

Provided by MedicineNet.com with Cleveland Clinic

 Diabetic Focal
Neuropathy
Symptoms may include:
double vision – eye pain
paralysis on one side of the face (Bell's Palsy)
severe pain in a certain area, such as the lower back or leg(s)
chest or abdominal pain that is sometimes mistaken for
another condition such as heart attack or appendicitis
Focal neuropathy is painful and unpredictable,
however, it tends to improve by itself over weeks or
months and does not tend to cause long-term
damage.
 Life Long Foot Care
Nail Care
Callus management
Regular examination
Inspect feet daily – use of a mirror
Cleanliness
Hydration practices
 Life Long Foot Care
Carefully wash & dry feet
Avoid soaking feet (maceration & bacterial
invasion)
Avoid walking barefoot
Protect against even minor trauma
Protective footwear
Pressure reduction – Off Loading
Prophylactic surgery
Prompt attention to ulceration
 Preventative Measures
Recommendations for:

• Therapeutic footwear (foot deformities) or

shoes that fit properly
• Orthotics
• Activity & Mobility counselling
(crutches/wheelchair)
 Footwear
Often shoes with extra deep (Oxford style)
and athletic shoes are sufficient

Rocker-sole shoes rock the foot from heel to

toe- with out bending the shoe and
creating pressure on the foot
 Footwear

Special soft insoles also reduce foot

pressures by as much as 50%

Socks with extra padding

 Footwear
Feet should be measured individually for
each shoe, should accommodate any minor
prominence and allow further pressure
relieving systems to be employed; soft
leather

Routine assessment of the shoes at follow up

appointments
 Footwear Essentials
Shape needs to match the foot
Insole
Extra depth toe box
Fit snug (not allow movement of foot inside
the shoe
Broad base
Thick sole
Low heel (not >1 inch)
Breathable material
Good closure – laces, Velcro
Smooth protective lining
Footwear

Ulcer recurrence with special footwear -

26%

Ulcer recurrence with regular footwear -

83%

(Edmonds et al, 1986)

 Pressure Off Loading
Total contact cast – gold standard- 75
-100% healing in 5 weeks
Removable cast walkers -easily removable
for inspection and treatment
Healing Sandals – rigid rocker to sole of
specially designed sandal -light weight,
stable, reusable
Crutches, walkers, wheelchairs
Ulna Boot
Air casts- fitted
Other Risk Factors for Ulceration
Blindness/partial vision/retinopathy
Chronic renal insufficiency
Diabetes duration
History of ulcers/amputations
Older age
Poor knowledge of Diabetes
Obesity
Socio-economic factors

always consider all the risks

 Physical Assessment

Inspection
Vascular assessment
Neurosensory
Testing
Footwear
Assessment Semmes-Weinstein Monofilaments
 When Ulcer Develops
Assess VIP

Critical
Triad

Vascular Supply Infection

Pressure (sensation/neuropathy)
Remember
to provide And
access to professional
appropriate care as
foot care indicated
teaching by need and
risk
assessment
 University of Texas
Risk Assessment
Diabetic Foot Categories
Category 0
Protective sensation intact
Foot deformity may be present
Treatment
Education
Screening
should be assessed twice yearly
 Categories 1-3
Risk Factors for Ulceration
Category 1
Loss of protective sensation (LOPS)
no foot deformities
No history of ulceration compared to
category 0
Treatment
appropriate shoe selection
Education
Monitor every 3-4 months
Category 2

LOPS & deformity or limited joint

mobility
12X's greater risk for ulceration then
category 0
Treatment
prescription extra depth shoes that
accommodate deformity
Education
Follow up every 2-3 months
 Category 3
History of previous pathology
36X'x greater risk of ulceration than category 0

Treatment
prescription extra depth shoes that accommodate
deformities
education
examination every 2-3 months
 Category 4
Risk Factors for Amputation
Category 4a
non-infected,non-ischemic wound
Treatment
strict offloading
seen weekly for evaluation,debridement,&
continuing education
Category 4b – Acute Charcot
arthropathy(presents initially as
red, hot , swollen)

Treatment
aggressive offloading & close mo
 Category 5
Diabetic Foot Infection – high risk for loss
of limb or life

Treatment
urgent medical/surgical management
Education & close monitoring
Category 6
critical ischemia, highest
risk for amputation

Treatment
Vascular surgery consult,
treatment for infection if
present
aggressive follow up for
limb salvage
 Diabetic Screening
Prevention
Annual screening consists of:
Monofilaments 10gm
Dermatemp- heat sensitive thermography
ABI – toe pressures
Harris- Beath Pressure Map – plantar
pressure
Foot Measurement – static and dynamic
Footwear assessment
Patient self care review and education
 Infections
Localized foot infection
redness, swelling to confined
area, heat
Management – oral antibiotics
good local wound care
Generalized foot infection
(Life & Limb Threatening)
entire foot red & swollen
may be complicated by Osteomylitis
 Infections

Management (generalized infection)

IV antibiotics
surgical interventions

Osteomylitis
X-ray, bone scan, MRI
higher doses of antibiotics for longer
periods of time
A Diabetic foot ulcer varies from a Arterial
ulcer in that with an Arterial ulcer-

A. Feet are warm to touch

B. Wound base light pink colour
C. Wound base red in colour
D. Callous wound edge
When the feet are cracked, dry and painful
this could be:

A. Motor Neuropathy
B. Standard Neuropathy
C. Sensory Neuropathy
D. Autonomic Neuropathy
Foot Ulcers are responsible for 60%

of all lower extremity amputation?

True

False
Foot assessments need to include
all except

A. Conversation with patient

B. Assessment of shoes
C. Mono filament testing
D. Massage
Prevention or treatment of
Diabetic Ulcers Should include
1. Glucose Monitoring
2. Diabetic Education Referral
3. Surgical Consult
4. Cognitive assessment

A. all of the above

B. None of the above
C. 1 & 3
D. 2 & 4
Foot assessments by a nurse need to be done

1. Monthly

2. With each hospital/office visit

3. When patient complains of problems

4. According to U of T Diabetic Foot Categories

5. All of the Above

What treatment management would you use
for this wound and what were your
assessments?
The initial treatment for Diabetic
Infection is surgical assessment
for amputation

True

False
 Questions?

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