Diabetic Ulcer

Prevention

• Education
  • Glycemic control
  • BP/LDL
  • Smoking
  • Activity/trauma
  • Footwear
  • Foot are (skin, nail care routine)
• Annual foot exam
  • Skin, structure (Charcot, clawtoe, hammertoe)
  • Vascular (pulses/temperature)
  • Footwear
    • Toe box should fit toes
    • Cushioning
  • r/o neuropathy
    • Monofilament test
• Therapeutic footwear/orthotics

Assess

• Ischemia
  • ABI
    • Ankle/pedal doppler arterial waveforms
    • Toe systolic pressure or TcPO2
• Infection
• Neuropathy

Management

Wound care

• Debridement q1-4w
  • Debris (biofilm)
  • Eschar/Devitalized tissue
  • Surrounding callus
• Moisture balance
  • Moist wound bed, control exudate, avoid maceration
• Bacterial balance
  • Topical vs. oral vs. IV antibiotics
• Consider negative pressure wound therapy if no healing despite 4-8 weeks of therapy

Offloading

• Relieve pressure
  • Total contact cast
  • Removable cast walker (can be rendered irremovable with tape)

PAD

• Vascular consultation
  • Revascularization

Osteomyelitis

• Suspect
  • Large ulcer >2cm^2
  • Deep ulcer >3mm
  • Probe-to-bone test
    • Serial X-ray
    • CRP>70 / ESR
  • If suspected osteomyelitis
    • CT vs. MRI vs. Bone Scan
    • Antibiotics
      • >4-6 weeks if no bone debridement
    • Orthopedics consultation
      • Bone debridement, biopsy, culture