DIABETIC FOOT ULCER

MANAGEMENT
POENGKI DWI POERWANTORO | PRASASTA ADHISTANA
PLASTIC RECONSTRUCTIVE AND AESTHETIC SURGEON
DIABETIC FOOT ULCER (DFU)
• DFUs are complex, chronic wounds, which have a major long-term impact on
the morbidity, mortality and quality of patients’ lives
• DFUs are relatively common — in the UK, 5–7% of people with diabetes
currently have or have had a DFU.
• Furthermore, around 25% of people with diabetes will develop a DFU during
their lifetime. Globally, around 370 million people have diabetes and this
number is increasing in every country.
ETIOLOGY OF DFU
In most patients, peripheral neuropathy and
peripheral arterial disease (PAD) (or both) play a
central role and DFUs are therefore commonly
classified as :
 Neuropathic
 Ischemic
 Neuroischemic

Neuroischemia : combined effect of diabetic

neuropathy and ischemia, whereby macrovascular
disease and, in some instances, microvascular
dysfunction impair perfusion in a diabetic foot.
DFU
Signs &
Symptoms
ASSESSING DFU
Patients with a DFU need to be assessed holistically and intrinsic + extrinsic factors are considered

For the non-specialist practitioner, the key skill required is knowing

when and how to refer a patient with a DFU to the multidisciplinary
footcare team (Surgeon and Wound Nurse).
HOLISTIC ASSESSMENT FOR DFU :

1. FULL HISTORY OF THE PATIENT, INCLUDING MEDICATION, COMORBIDITIES, DIABETES STATUS

2. CLINICAL EXAMINATION OF THE ULCER
3. DOCUMENTING ULCER CHARACTERISTIC BY PHOTOGRAPH
4. TESTING FOR LOSS OF SENSATION
5. TESTING FOR VASCULAR STATUS
6. IDENTIFYING INFECTION
7. INSPECTING FEET FOR DEFORMITIES
A CLINICAL EXAMINATION OF THE DFU SHOULD DETER
Is the wound predominantly neuropathic, ischemic or neuroischemic?

If ischemic, is there critical limb ischemia? Are there any musculoskeletal deformities?

What is the size/depth/location of the wound? What is the color/status of the wound bed?
Black (necrosis), Yellow, Red, Pink ?

Is there any exposed bone? Is there any necrosis or gangrene? Is the wound infected? If so, are
there systemic signs and symptoms of infection (such as fevers, chills, rigors, metabolic instability
and confusion)?

Is there any malodor? Is there local pain? Is there any exudate? What is the level of
production (high, moderate, low, none), color and consistency of exudate, and is it
purulent?

What is the status of the wound edge (callus, maceration, erythema, edema, undermining)?
 WOUND
DOCUMENTATION

Digitally photographing DFUs at the first consultation and

periodically thereafter to document progress is helpful.

This is particularly useful for ensuring consistency of care among

healthcare practitioners, facilitating telehealth in remote areas and
illustrating improvement to the patient.
TEST FOR NEUROPATHY (1)
Two simple and effective tests for peripheral
neuropathy are commonly used:

 10g (Semmes-Weinstein) monofilament

 Standard 128Hz tuning fork.

The 10g monofilament is the most frequently

used screening tool to determine the presence
of neuropathy in patients with diabetes.

A positive result is the inability to feel the

monofilament when it is pressed against the foot
with enough force to bend it.
TEST FOR NEUROPATHY (2)
Apply a vibrating 128 Hz Tuning Fork to the bony prominence of the Big Toe.

If the patient cannot feel the vibration, gradually move fork upwards.

Neuropathy is
demonstrated by an
inability to sense vibration
from a standard 128 Hz
tuning fork.
TESTING FOR VASCULAR STATUS (1)

Palpation of peripheral pulses

should be a routine component of
the physical examination and
include assessment of the
femoral, popliteal and pedal
(dorsalis pedis and posterior
tibial) pulses.
TESTING FOR
VASCULAR STATUS (2) :
Ankle Brachial Pressure Index
Where available, Doppler
ultrasound, ankle-brachial
pressure index (ABPI) and
Doppler waveform may be used
as adjuncts to the clinical
findings.
IDENTIFYING INFECTION (1)
Recognizing infection in patients with DFUs can be challenging, but it is one of the
most important steps in the assessment, what is often progression from simple
(mild) infection to a more severe problem, with necrosis, gangrene and
often amputation.

Around 56% of DFUs become infected and overall about 20% of patients with an
infected foot wound will undergo a lower extremity amputation.

If infection is suspected, practitioners

should take appropriate cultures,
preferably soft tissue (or bone when
osteomyelitis is suspected), or
aspirations of purulent secretions.
IDENTIFYING INFECTION (2) : Osteomyelitis
Osteomyelitis may frequently be
present in patients with moderate to
severe diabetic foot infection. If any
underlying osteomyelitis is not
identified and treated appropriately,
the wound is unlikely to heal.

Plain x-rays can help to confirm the

diagnosis, but they have a relatively
low sensitivity (early in the infection)
and specificity (late in the course of
infection) for osteomyelitis.
INSPECTING FEET FOR DEFORMITIES
Excessive or abnormal plantar pressure, resulting from
limited joint mobility, often combined with foot
deformities, is a common underlying cause of DFUs in
individuals with neuropathy.

Typical presentations resulting in high plantar

pressure areas in patients with motor
neuropathy are:
 A high-arch foot
 Clawed lesser toes
 Visible muscle wasting in the plantar arch and on the
dorsum between the metatarsal shafts (a ‘hollowed-out’
appearance)
 Gait changes, such as the foot ‘slapping’ on the ground
 Hallux valgus, hallux rigidus and fatty pad depletion.
DFU Wound Management
THE ESSENTIAL COMPONENTS OF
DFU WOUND MANAGEMENT ARE :

1. Treating underlying disease process

2. Ensuring adequate blood supply
3. Local wound care, including
infection control
4. Pressure offloading
1. TREATING UNDERLYING DISEASE PROCESS

Treating any severe ischemia is critical to wound healing,

regardless of other interventions. It is recommended that all patients with critical limb
ischemia, including rest pain, ulceration and tissue loss, should be referred for consideration
of arterial reconstruction.

Achieving optimal diabetic control. This should involve tight

glycemic control and managing risk factors such as high blood pressure, hyperlipidemia and
smoking. Nutritional deficiencies should also be managed.

Addressing the physical cause of the trauma. As

well as examining the foot, practitioners should examine the patient’s footwear for proper fit,
wear and tear and the presence of any foreign bodies (such as small stones, glass
fragments, drawing pins, pet hairs) that may traumatize the foot.
2. ENSURING ADEQUATE BLOOD SUPPLY

Decreased perfusion or
impaired circulation may
be an indicator for surgical
revascularization in order
to achieve and maintain
healing and to avoid or
delay a future amputation.
3. LOCAL WOUND CARE FOR DFU

The European Wound Management Association

(EWMA) states that the emphasis in wound care for DFUs should be on :
radical and repeated debridement, frequent
inspection and bacterial control and careful
moisture balance to prevent maceration.
Its position document on wound bed preparation
suggests the following TIME framework for managing DFUs (see next
slide).
TIME >> A Practical Framework for Wound Bed Preparation

Tissue management Tissue debridement

Control of Infection and inflammation

Epithelial Infection
Wound bed
Edge Inflammation
Moisture balance preparation

Advancement of the epithelial Edge of Moisture balance

the wound.
Negative
Pressure
Wound
Therapy
(NPWT)

Modern Dressings
Dressing Guide (2)
DEBRIDEMENT + NPWT + SKIN GRAFT FOR DFU
DEBRIDEMENT + LOCAL FLAP RECONSTRUCTION FOR DFU
DEBRIDEMENT + PRP INJECTION + SKIN GRAFT FOR DFU
DEBRIDEMENT + REVERSE SURAL FLAP RECONSTRUCTION FOR DFU
4. PRESSURE OFFLOADING

In patients with peripheral

neuropathy, it is important to
offload at-risk areas of the foot
in order to redistribute
pressures evenly.

Inadequate offloading leads to

tissue damage and ulceration.
THANK YOU
Correspondence :
poengkid@yahoo.com | prasastaadhistana@gmail.com