The following will briefly discuss ideas related to the specific cause, diagnostics, appearance, and treatment of the diabetic foot wound etiology.
Diabetic wounds are related to microvascular and neuropathic changes in the diabetic patient. Diagnosis of the diabetic ulcer includes a compatible history of diabetes, monofilament test (to assess for loss of sensation), and noninvasive vascular assessments including a transcutaneous oxygen monitoring (TCOM) study. Treatment options for diabetic ulcers include off loading, growth factors (Regranex), debridement, and skin substitutes (Apligraf and Dermagraft).
Diabetic wounds place patients at high risk for infection including osteomylitis. Diabetics can also suffer from gangrenous wounds (see photo). Because of these risks approximately 15% of Diabetic Foot Ulcers result in lower extremity amputation (2). Though 40% to 50% of all diabetes-related amputations are preventable (1) . Foot-care programs for diabetics (including teaching self foot assessments) have been shown to reduce the rate of ulcers and amputations by 45% to 85% (1).
1. Garcia – Diaz, J., Pankey, G., & Gentry, Layne., 2006. The contemporary Diagnosis and Management of Diabetic Foot Infections. Health Care Co., Newtown, Pennsylvania. pg.16
2. Snyder, R., Kirsner, R., Warriner, R., Lavery, L., Hanft, J. and Sheehan, P., April 2010. Consensus recommendations on advancing the standard of care for treating neuropathic foot ulcers in patients with diabetes. Supplement to April 2010 OWM, S4.
Diabetic Wound Related Terms:
Diabetic (Neuropathic) Ulcer – Sensory neuropathy involving the feet may lead to unrecognized episodes of trauma caused by ill-fitting shoes or walking barefoot. This is compounded by motor neuropathy causing intrinsic muscle weakness and spaying of the foot on weight bearing. The result is a convex foot with a rocker-bottom appearance. Multiple fractures go unnoticed, until bone and joint deformities become marked. This is termed a Charcot foot (ie, neuropathic osteoarthropathy) and is observed most commonly in people with diabetes mellitus, affecting approximately 2% of persons with diabetes.
Diabetes: The long-term effects of diabetes impair wound healing by diminishing sensation and arterial inflow. In addition, even acute loss of diabetic control can affect wound healing by causing diminished cardiac output, poor peripheral perfusion, and impaired polymorphonuclear leukocyte phagocytosis.
DIABETIC ULCER – An ulcer that develops due to diabetic risk factors. Diabetes affects circulation as well as the nerve endings in the feet. As a result, many diabetics suffer reduced circulation and loss of sensation in their feet. The loss of sensation is dangerous, because diabetics are unable to feel rubbing, pinching or other pain that could cause a wound to develop on the foot. Lack of circulation to the feet makes it very difficult for a wound to heal. Risk factors for developing a diabetic foot ulcer include loss of sensation or peripheral neuropathy, structural foot deformity, infection, and decreased circulation.
Charcot Foot (Arthropathy) –Acute- Foot deformity with sudden onset of swelling,
increased local skin temperature, erythema, rapid joint changes, looseness of ligaments,
dislocation and fractures without apparent cause.
Charcot Foot (Arthropathy -Chronic -progressive degeneration of the stress-bearing
portion of a joint, with hypertrophic changes at the periphery. It is manifested by rapid
joint changes, looseness of ligaments, dislocation and fractures.
HgbA1c – Glycated hemoglobin, also known as glycohemoglobin, glycosylated hemoglobin, HbA1c or HbA1, refers to a series of stable hemoglobin components formed by the combination of glucose and hemoglobin. Individuals with higher levels of blood glucose will have higher levels of glycated hemoglobin. Because the hemoglobin
components are stable, the level provides an average indication of the overall blood glucose levels over the prior two to three month period. The most commonly used version of the glycated hemoglobin test is the HbA1c.
Hyperkeratotic – Hypertrophy of the horny layer of skin and often appears as a callus ring around a diabetic wound.
Monofilament Test or Semmes Weinstein Monofilament Test – Is a sensory exam of the foot to detect sensory neuropathy – a 10 gram monofilament
which is pressed to several sights on the feet for 1.5 seconds on each sight and the patient is asked to say “yes” when the monofilament is felt.
Orthotics – a full contact semi rigid, soft insert designed to redistribute pressure, reduce impact, shear and stabilize involved joints. A suitable prescription should include a
complete diagnosis, reflecting the risk category of the patient. Orthotics must be casted and fitted appropriately by an experienced professionally trained clinician.
Osteomyelitis – Inflammation of bone and marrow, usually caused by infection.
Gangrene- Death of cells with the appearance of a dessicated or shriveled tissue area related to poor perfusion.
Matthew Livingston R.N. C.W.S.
