What are diabetic foot ulcers?

Updated: Oct 15, 2020
  • Author: Tanzim Khan, DPM; Chief Editor: Romesh Khardori, MD, PhD, FACP  more...
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Answer

Diabetic foot ulcers, as shown in the images below, occur as a result of various factors, such as mechanical changes in conformation of the bony architecture of the foot, peripheral neuropathy, and atherosclerotic peripheral arterial disease, all of which occur with higher frequency and intensity in the diabetic population. [1, 2]

Diabetic ulcer of the medial aspect of left first Diabetic ulcer of the medial aspect of left first toe before and after appropriate wound care.
Diabetic ulcer of left fourth toe associated with Diabetic ulcer of left fourth toe associated with mild cellulitis.

Nonenzymatic glycation predisposes ligaments to stiffness. Neuropathy causes loss of protective sensation and loss of coordination of muscle groups in the foot and leg, both of which increase mechanical stresses during ambulation.

Diabetic foot lesions are responsible for more hospitalizations than any other complication of diabetes. [3] Diabetes is the leading cause of nontraumatic lower extremity amputations in the United States, with approximately 5% of diabetics developing foot ulcers each year and 1% requiring amputation.

Physical examination of the extremity that has a diabetic ulcer can be divided into examination of the ulcer, examination of the feet, assessment of the possibility of vascular insufficiency, [4] and assessment for the possibility of peripheral neuropathy.

Diabetic foot ulcers can be staged using the Wound, Ischemia, and foot Infection (WIfI) threatened limb classification system. This system allows communication between providers and provides risk stratification for major amputation. [5] Blood work should be obtained, such as a complete blood count (CBC), a comprehensive metabolic panel, and hemoglobin A1c (HbA1c), as well as inflammatory markers when infection is suspected. Weight-bearing radiographs of the affected limb should be obtained.

The management of diabetic foot ulcers requires offloading the wound, [6, 7] daily saline or similar dressings to provide a moist wound environment, [8] débridement when necessary, antibiotic administration with or without surgical intervention if osteomyelitis or soft tissue infection is present, [9, 10] optimal control of blood glucose, and evaluation and correction of peripheral arterial insufficiency. [11]

All patients harboring diabetic foot ulcers should be evaluated by a qualified vascular surgeon and podiatric surgeon who will consider  débridement, reconstructive surgery on bony architecture, vascular reconstruction, and options for soft tissue coverage.

It is prudent to address the underlying etiologies in diabetic foot ulcers for wound care modalities to be successful. Without addressing the osseous deformities and muscular imbalances, infections, and vascular insufficiency, there will be of minimal benefit in employing advanced wound care dressings.

For more information, see Diabetes Mellitus, Type 1 and Diabetes Mellitus, Type 2.


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