II. Differential Diagnosis
III. Findings: Red Flags suggestive of Foot Osteomyelitis
- Sausage toe (swollen, deformed red toe)
- Bone Visualized or Probe-to-Bone Test positive
-
Skin Ulcer with red flags
- Infected ulcer with ESR >70 mm/h or unexplained Leukocytosis
- Non-healing ulcer despite several weeks of wound care and non-weight bearing
- Non-healing ulcer over bony prominences despite wound care
- Ulcer with underlying bony XRay changes
- Ulcer area >2 cm^2
- Ulcer depth >3 mm
IV. Classification: Diabetic Foot Ulcer
V. Grading: Diabetic Wound Severity
- Not infected
- Wound without purulence or inflammation
- Mild Infection
- Wound with purulence and inflammation
- Localized infection that does not extend more than 2 cm beyond ulcer margins
- Moderate Infection
- Regional infection extending more than 2 cm beyond ulcer margins
- Ascending lymphangitis with deep infection
- Severe Infection
VI. Evaluation
- Evaluate foot neurovascular status
- Bone Visualized or Probe-to-Bone Test positive
- Treat as presumptive Osteomyelitis
-
Osteomyelitis XRay consistent with Osteomyelitis
- Treat as presumptive Osteomyelitis
-
Osteomyelitis XRay not consistent with Osteomyelitis
- Severe Peripheral Neuropathy or high suspicion
- Obtain Osteomyelitis Bone Scan or Osteomyelitis Bone MRI
- Positive: Treat as presumptive Osteomyelitis
- Negative: Treat as Soft Tissue infection
- Obtain Osteomyelitis Bone Scan or Osteomyelitis Bone MRI
- Lower suspicion for Osteomyelitis
- Treat as Soft Tissue Infection
- Severe Peripheral Neuropathy or high suspicion
VII. Management: General
- Background
- Chronic diabetic Osteomyelitis is typically a slow, indolent infection without systemic toxicity
- Contrast with Acute Osteomyelitis from hematogenous spread (typically in ill appearing children)
- Chronic diabetic Osteomyelitis is typically a slow, indolent infection without systemic toxicity
-
Wound Care
- Cleanse and debride wound
- Unload the wound (e.g. non-weight bearing)
- Consider Wound Healing agents
- Evaluate foot wear
- Obtain wound culture and Gram Stain
- Mild to moderate infections
- Choose parenteral or oral agents as below
- Reevaluate every 2-3 days until improving
- Treat as severe infection if lack of improvement
- Severe infections
- Hospitalize and treat with parenteral agents
- Obtain deep wound culture (consider bone biopsy and culture)
- Reevaluate twice daily
- Consider orthopedic surgery for bone biposy or resection
- Consider vascular surgery for revascularization considerations
- Consider hyperbaric oxygen or Granulocyte stimulating factors
VIII. Management: Antibiotic Course
- Soft tissue infection
- Bone infection
- Post-amputation without residual infection: 2-5 days of antibiotics
- Residual infected viable bone: 4-6 week total course
- Residual infected dead bone: 8-12 week total course
IX. Management
- See Diabetic Foot Infection for initial antibiotic coverage
- Try to obtain bone culture prior to starting antibiotics in Osteomyelitis
