- Diabetics are prone to foot ulcerations due to both neurologic and vascular complications.
- Peripheral neuropathy can cause altered or complete loss of sensation in the foot and /or leg. Similar to the feeling of a "fat lip" after a dentist's anesthetic injection, the diabetic with advanced neuropathy looses all sharp-dull discrimination. Any cuts or trauma to the foot can go completely unnoticed for days or weeks in a patient with neuropathy. It's not uncommon to have a patient with neuropathy tell you that the ulcer "just appeared" when, in fact, the ulcer has been present for quite some time. There is no known cure for neuropathy, but strict glucose control has been shown to slow the progression of the neuropathy.
- Charcot foot deformity occurs as a result of decreased sensation. People with "normal" feeling in their feet automatically determine when too much pressure is being placed on an area of the foot. Once identified, our bodies instinctively shift position to relieve this stress. A patient with advanced neuropathy looses this important mechanism. As a result, tissue ischemia and necrosis may occur leading to plantar ulcerations. Microfractures in the bones of the foot go unnoticed and untreated, resulting in disfigurement, chronic swelling and additional bony prominences.
- Microvascular disease is a significant problem for diabetics and can lead to ulcerations. It is well known that diabetes is called a small vessel disease. Most of the problems caused by narrowing of the small arteries cannot be resolved surgically. It is critical that diabetics maintain close control on their glucose level, maintain a good body weight and avoid smoking in an attempt to reduce the onset of small vessel disease.
- Treatment: First, you must determine the cause of this ulcer. Is it neuropathic, ischemic or a combination? Base your treatment protocol on the etiology of the ulcer. Assuming that there is adequate perfusion to heal a plantar ulcer, one should have appropriate shoe modifications made to disperse weight away from the ulcerative area. Absorb any excess discharge and maintain a moist wound environment with appropriate product selection. Keep the wound edges dry. Make sure no sinus tracking occurs. Watch for infection. Debride necrotic debris and the hyperkeratotic rim as they are niduses of for infection.
Case Study: This patient is an insulin dependent diabetic who presented with the above ulcer. The lesion was present for almost 3 years. Treatment consisted of wound cleansing, aseptic surgical debridement, application of castellani's paint to the wound edges, a hydrogel to the wound base covered by Allevyn foam dressing. Molded shoes with a plastizote insert were also obtained.
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