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 Measurements and Examination

Complete ulcer measurements along with other qualitative and quantitative assessments need to be included in the patient's record at the initial and all subsequent visits. Wound measurements and data assist with determining wound progress and effects of treatment. Wound depth may affect the choice of treatment. When deep structures are involved, particularly in the case of bone, osteomyelitis must be ruled out. The presence of purulent exudate is an indicator of clinical infection and requires appropriate antibiotic therapy. Purulent drainage may be mimicked by residue from dressings including, but not limited to, alginates, hydrocolloids, and collagens. Once a dressing has been removed and the wound is cleaned, purulence should not be present. Odor alone may be the result of contamination or colonization and is not necessarily an indicator of clinical infection.[30]

Assessment of periwound area is important. The presence of erythema, maceration, and tissue breakdown are indicators of additional complications, which may interfere with wound closure.

Infection must be recognized and treated without delay. Limb-threatening bacterial infections of diabetic foot ulcers are usually polymicrobial.[2,31] The potential for rapid deterioration in infected diabetic ulcers warrants the immediate use of a broad-spectrum antibiotic, which later can be modified based on culture results. Deep specimens and biopsies provide the most accurate results, although white blood cell (WBC)-labeled scans may also be used to assist with diagnosis.[32] Bone exposure closely correlates with ostemyelitis.[29,33] A standard radiological exam may assist with the diagnosis but is not as reliable as magnetic resonance imaging (MRI). Standard radiographic films have poor sensitivity and specificity for early osteomyelitis. However, standard x-rays should be taken for every new patient and used as a baseline comparison for x-rays taken later in a patient's treatment regimen. The x-rays can be used to rule out boney abnormalities, gas, and foreign bodies. Changes in subsequent radiographs compared with baseline radiographs may provide useful data on progression of osteomyelitis.


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