Diabetic Foot Ulcer

1. Pathophysiology
   1. Sensory protection is lost
      1. Results in chronic trauma
      2. Tissue breaks down in traumatized area
      3. Charcot changes result in additional pressure points
   2. Complicating factors
      1. Peripheral Vascular Disease
      2. Osteomyelitis
2. Evaluation: General
   1. Assess for Osteomyelitis
   2. Assess for foreign body
   3. Assess for Peripheral Vascular Disease
3. Evaluation: Inpatient Criteria for Foot Wound with Limb-Threatening Infection
   1. Extensive Cellulitis (>2 cm)
   2. Ascending lymphangitis
   3. Deep abcesses
   4. Osteomyelits
   5. Gangrene
   6. Critical limb ischemia
   7. Probe extends to bone (probe to bone test)
   8. Frykberg (2006) J Foot Ankle Surg 45(5 Suppl):S1-66
4. Management: Outpatient
   1. Offloading is key
      1. Ongoing trauma persists until non-weight bearing
      2. Options
         1. Use Crutches, walker or wheelchair
         2. Darko Shoe (half shoe not offloads distal foot)
         3. CAM Walker or cast
   2. Dressings (moist healing is critical)
      1. Wet-to-Moist Dressing (cost effective, first line)
      2. Silver products (e.g. Acticoat)
      3. Debridement salves (e.g. accuzyme)
      4. Other more complex and expensive options
         1. Promogran
         2. Becaplermin (Regranex)
         3. Bioengineered skin graft
   3. Determine if antibiotics are appropriate
   4. Remove Callus (causes pressure areas)