By Dr S P Pradhan on 7th September, 2023
Diabetes foot ulcer is one of the complicated phenomenon arising out of poorly managed diabetes glycemic control.
Diabetes is a ever growing problem now a days. The complications are bound to be there in long standing cases. Diabetic neuropathy, poor sugar control, existing risk factors like obesity, peripheral vascular disease add to the woes.
Risk factors of Diabetic foot ulcer
• Long standing cases of diabetes with poor glycemic control
• Obesity causing pressure sores
• Peripheral vascular disease like Buerger’s disease
• Diabetic neuropathy causing decreasing sensations over foot
• Foot deformity
• Improper footware causing increased pressure
• Poor vascularity of the area
Grades of diabetic foot ulcer
Grade 1- Superficial ulcer involving skin and superficial tissue
Grade 2- Deep ulcer involving tendon, ligaments and muscle
Grade 3- Deep ulcer involving bone tissue like osteomyelitis
Grade 4- Ulcer affecting the forefoot causing gangrene
Grade 5 – Ulcer affects whole foot causing gangrene
Clinical Examination
Proper clinical examination prior to management of is very vital in treatment. Duration of diabetes, associated comorbid conditions, any existing peripheral vascular disease, dependent on insulin or oral drugs, compliance to the drugs, interval of testing and attending to the physician should be ruled out. Detailed examination about peripheral neurological insufficiency should be done. Checking foot deformity, callus, peripheral pulses, depth of ulcer and encroachment to surrounding areas should be checked.
The most common sites of diabetic foot ulcer are plantar metatarsal head, heel, tips of the toes.
Photo credit- Dreamstine
Those areas having pressure bearing points are most susceptible to ulcer. Signs of peripheral neuropathy are altered sensation, pain, diminished sensation and atrophy of the muscles of that area.
Investigation
The biochemical profiles like complete blood count, fasting blood sugar, post prandial blood sugar, glycated hemoglobin, serum sodium, potassium and creatinine, ESR, nerve conduction studies should be estimated. Swabs from site of ulcer should be taken to determine type of organism and antibiotic sensitivity.
Radiological examination with simple x ray of foot should be done to look for degree of deep tissue or bone involvement. MRI of bony tissue or bone scan with technetium done to rule out degree of ulcer with bone involvement. Ankle brachial index(ABI) done in suspected peripheral vascular diseases.
Management
The prognosis of treatment of diabetic foot ulcer mostly dependent on blood sugar regulation and initial evaluation before progression of disease.
Antibiotics are the mainstay of treatment. They are usually given according to culture senstitivity of the swab. The most common pathogenic organisms are staphylococcus, streptococcus, pseudomonas. The common antibiotics given are amoxycillin clavulanic acid, metronidazole for anaerobic coverage, ciprofloxacin and cephalosporins. Cephalosporins are usually given as injectables. The injectables given are ampicillin sulbactam, ceftriaxone, piperacillin tazobactam, meropenam. If MRSA is suspected, linezolid, vancomycin are given.
Local debridement of dead tissue improves the oxygenation to the area. Treatment of any peripheral vascular diseases should be done. Washing with antibiotic solutions and superoxide solutions done to prevent reinfection.
Vacuum assisted closure done for treatment of non healing ulcers. Hyperbaric oxygen therapy done in cases of non healing ulcers to improve oxygenation of the areas.
Anatomical deformities should be wear specially made braces or shoes. Severe cases of anatomical defect may require arthrodesis or osteotomy. Prevention of pressure points from recurrent ulcers done by using therapeutic walkers or shoes.
Proper rest and adequate nutrition are important for healing of wounds. Supportive vitamin C and B-complex vitamins can be taken for better results.
Complications
Gangrene of the foot, sepsis, deep non healing ulcers are the complications.
