III. Grading: Classification Systems for Diabetic Foot Ulcers

IV. Evaluation

  1. See Suspected Osteomyelitis in Diabetes Mellitus
  2. Assess vascular status
    1. Palpate popliteal pulse (should be present)
    2. Palpate pedal pulse
      1. Often absent in diabetic arterial disease
      2. Diabetes selectively affects distal tibial artery

V. Management

  1. All foot lesions
    1. Reduce pressure on foot lesion
      1. Crutches
      2. Cam-walker (or total contact Casting, other off-loading devices)
      3. Surgical shoe with cushioned insert
      4. Dressings: Foam or felted foam
    2. Optimize comorbid conditions
      1. Control Hypertension
      2. Improve glycemic control
      3. Maximize nutritional status
  2. Closed Foot Sores
    1. Warm water soaks (not hot) for 15 minutes twice daily
      1. Epson salts added to water may be soothing
    2. Hypoallergenic lotion to affected area bid
    3. Cotton socks
  3. Ulcerated wounds
    1. See Wound Cleansing
    2. See Wound Debridement (debride necrotic tissue)
    3. Choose dressing to maintain warm, moist environment
      1. See Wound Dressing (inc. Pressure Sore Dressings)
      2. Hydrocolloid Dressing (avoid if wound infected)
      3. Transparent Film Dressing (avoid if wound infected)
      4. Foam Dressing
      5. Calcium Alginate Dressing
    4. Consider adjuncts to promote Wound Healing
      1. Growth factors (e.g. Becaplermin)
      2. Bioengineered skin grafts (Apligraf, Dermagraft)
  4. Ischemic wounds
    1. Revascularization or Angioplasty
    2. Hyperbaric oxygen therapy
      1. Reduces amputations due to Diabetic Foot Ulcers
      2. Roeckl-Wiedmann (2005) Br J Surg 92:24-32 [PubMed]
    3. Vasodilator drugs have not been efficacious
  5. Infected wounds
    1. See Cellulitis for infected diabetic wound management
    2. Findings suggestive of serious infection
      1. Cellulitis involves >2 cm of skin
      2. Deep ulcer
      3. Purulent drainage
      4. Fever
      5. Probe-to-Bone Test positive
        1. See Suspected Osteomyelitis in Diabetes Mellitus

VI. Prevention

VII. Prognosis: Foot Ulcer healing in Diabetes Mellitus

  1. Healing prediction based on 3 criteria (one point each)
    1. Foot Wound present >2 months
    2. Foot Wound >2 cm
    3. Grade 3 or more on Wagner Ulcer Classification
  2. Interpretation: Score of 2 or more
    1. Wound not healed in 79% of patients by 20 weeks
  3. References
    1. Margolis (2003) Am J Med 115:627-31 [PubMed]

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