Standard, Appropriate, and Advanced Care and Medical-Legal Considerations: Part One -- Diabetic Foot Ulcerations

Gerit Mulder, DPM, MS, David Armstrong, DPM, Susie Seaman, MSN, NP, CETN


Wounds. 2003;15(4) 

In This Article

Ulcer Treatment

Guidelines for general care of the diabetic foot ulcer were established by the American Diabetes Association (ADA). The ADA 1999 Clinical Practice Recommendations[2] list the following recommendations for foot care in patients with diabetes mellitus:

Prompt and proper care of diabetic foot ulcers is essential. The healthcare professional should 1) establish the ulcer's etiology; 2) measure its size; 3) establish its depth and determine the involvement of deep structures; 4) examine it for purulent exudate, necrosis, sinus tracts, and odor; 5) assess the surrounding tissue for signs of edema, cellulitis, abscess, and fluctuation; 6) exclude systemic infection; and 7) perform a vascular evaluation. The ability to gently probe through the ulcer to bone has been shown to be highly predictive of osteomyelitis.[29]

The above guidelines recommend components of care but neither delineate what is appropriate for each patient nor describe advanced modalities, which may expedite closure. A more in-depth understanding of each component of treatment will assist in providing appropriate and advanced care.

Establishing the ulcer's etiology is necessary if one is to treat appropriately. As previously mentioned, vascular status must be examined to determine the degree of flow. When severe occlusion is present, surgical intervention may be recommended. Vasodilators have not been proven to assist with the healing of diabetic foot ulcers. Vasoconstricting drugs need to be avoided in the diabetic patient.[2] Sharp debridement is contraindicated in the presence of severe occlusion. If the patient has a dry intact eschar, do not debride, but if it is wet and loose, the loose tissue should be removed gently without causing damage to viable tissue. Diabetic patients may also present with lower-extremity ulcers of venous, vasculitic, or other etiologies. The underlying pathophysiology needs to be addressed even when it is not related to diabetes. Misdiagnosis may result in a higher incidence of morbidity and mortality.


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