Grand Mentor : Dato Dr Hj Zamyn Zuki

Mentor : Mr. Lim Sze Wei

My Mentor

Objective
To understand about diabetes foot ulcer
Learn on how to take full history in patient presenting with diabetic

foot ulcer

Learn to do appropriate physical, foot and ulcer examination

Learn about the necessary investigations required for diagnosis and

appropriate management

Wagners classification of diabetic foot ulcer

Management of diabetic foot ulcer

Introduction
Diabetic foot is a disease complex that can develop in the skin,

muscles, or bones of the foot as a result of the nerve damage,

poor circulation and/or infection that is associated with
diabetes.

The Diabetic Foot may be defined as a syndrome in which

neuropathy, angiopathy, and infection will lead to tissue

breakdown resulting in morbidity and possible amputation
( WHO 1995 )

Any foot pathology that result from diabetes or its long term

results (Boulton 2002)

Risk for Ulceration

Aetiopathogenesis

Neuropathy

Physical examinations
General

Local

Signs of inflammation
Pyrexia
Ascending infection
Sepsis

Musculoskeletal Status

Vascular Status
Neurological Status

Attitude and posture of

lower limb and foot

Deformities e.g. calluses,

Charcot deformity

Ulcer examination

Skin and Nails

Patient's Footwear

Previous amputations

Range of movement

Tendon contractures

Hallux Valgus Deformity

Hammer toe / Claw toe

deformity

Physical examinations
General

Local

Signs of inflammation
Pyrexia
Ascending infection
Lymphagitis
Sepsis

Musculoskeletal Status

Pulses ( dorsalis pedis,

posterior tibial, popliteal,

Vascular Status

femoral)

Neurological Status
Ulcer examination

Capillary return (normal <2

secs)

Presence of oedema

Appearance: Swelling,
erythematous, cyanosis

Skin and Nails

Patient's Footwear

Ischaemic changes: skin &

nail atrophy, abnormal
wrinkling, loss of hair

Physical examinations
General

Local

Signs of inflammation
Pyrexia
Ascending infection
Lymphagitis
Sepsis

Musculoskeletal Status

fork 128 Hz

Vascular Status

Neurological Status
Ulcer examination

Skin and Nails

Patient's Footwear

Vibration perception: tuning

Pressure and touch:

cotton wool

Monofilament 10gm

Pain: pinprick

Two point discrimination

Reflexes: ankle and knee

Physical examinations
General

Local

Signs of inflammation
Pyrexia
Ascending infection
Lymphagitis
Sepsis

Musculoskeletal Status

Location, size, depth,

margins, swelling, colour,
odour, base, floor and type

Vascular Status

of discharge

Neurological Status

Attempts to express pus/

discharges

Ulcer examination

Dermatologic Examination
Patient's Footwear

Type of ulcer

Neuropathic

Ischaemic

Neuro-ischaemic

STAGES OF ULCER DEVELOPMENT

STAGES OF ULCER DEVELOPMENT

Features of Ulcers
Feature

Neuropathic

Ischaemic

Neuroischaemic

Sensation

Sensory loss

Painful

Degree of sensory
loss

Callus/necrosis

Calluses present
++ thick

Necrosis common

Minimal callus
Prone to necrosis

Wound

Pink
++ granulation

Pale, sloughy
Poor granulation

Poor granulation

Foot temperature
and pulses

Warm
Bounding pulse

Cool
Absent of pulse

Cool
Absent of pulse

Location

Weight bearing areas

e.g metatarsal
heads, heel

Tips of toes
Nail edges
Between toes
Lateral borders of
foot

Margins of the foot

and toes

Others

Dry skin and

Delayed healing

High risk of infection

Physical examinations
General

Local

Signs of inflammation
Pyrexia
Ascending infection
Lymphagitis
Sepsis

Musculoskeletal Status
Vascular Status

Skin appearance

Neurological Status

Ulcer examination

Dermatologic Examination

Callouses
Fissures (especially
posterior heels)
Nail appearance
Ulceration, gangrene,
infection

Patient's Footwear

Colour, texture, turgor,

quality
Dry skin

Note location, size,

depth, infection status

Interdigital pedis

Physical examinations
General

Local

Signs of inflammation
Pyrexia
Ascending infection
Lymphagitis
Sepsis

Musculoskeletal Status
Vascular Status
Neurological Status
Ulcer examination

Dermatologic Examination
Patient's Footwear

Type of shoe
Fit
Insoles
Foreign body

WAGNER CLASSIFICATIONS OF DFU

Grade

Descriptions

Pre-ulcer. No open lesion. May have deformities, erythematous

areas of pressure or hyperkeratosis

Superficial ulcer. Disruption of skin without penetration of

subcutaneous fat layer

Full thickness ulcer. Penetrates through fat to tendon or joint

capsule without deep abscess or osteomyelitis.

Deep ulcer with abscess, osteomyelitis or joint sepsis. It includes

deep plantar space infections, abscesses, necrotizing fascitis and
tendon sheath infections.

Gangrene of a geographical portion of the foot such as toes,

forefoot or heel.

Gangrene or necrosis of large portion of the foot requiring major

limb amputation.

 Superficial ulcer.
No penetration of subcutaneous fat layer

 Full thickness ulcer

Penetrates through fat to
tendon or joint capsule
No deep abscess or
osteomyelitis.

Deep ulcer
Abscess
Osteomyelitis
Joint sepsis

 Localised gangrene
toes, forefoot or heel

 Extensive gangrene
Entire foot or leg

Investigations
Biochemical

Radiological

FBS or RBS

Plain radiograph

HbA1C

FBC

Features of OM, osteolysis,

fractures, dislocations, soft-tissue
gas and Charcots joint

ESR

CT scan

RP/BUSE

Tissue/Pus & Blood C&S

delineate suspected bone or joint

pathology not evident on plain
radiographs

Urine FEME & C&S

MRI
important imaging modality in
diabetic patients with foot
infections
allows evaluation of both softtissue and bone pathologies

Vascular
To assess blood flow and healing
potential
Ankle Brachial Systolic
Index (ABSI)
Abnormal result + non healing
ucer may warrant further
vascular work up

Cornerstone of Management
Regular inspection and examination
Identification of the foot at risk
Education
Appropriate footwear
Treatment of non-ulcerative pathology

Management of limb at
risk of ulceration
Managed as outpatient
Should be re-assessed annually
Prevention

Pre-ulcer with intact skin

Foot at risk
Bony deformities
Erythematous
Hyperkeratosis

Education
Foot care
Foot ware
Reduction of plantar
pressure (off-loading
Correctional surgery (e.g.
hammertoes, bunions)

Management of Grade 1 & 2

ulcer
Managed as outpatients
Bedside wound debridement/desloughing
Good local wound care

Daily normal saline dressing

Relief of pressure on the ulcer
To allow ulcer to heal
Antibiotic treatment for 1 to 2 weeks
Education
Close monitoring and diabetes management
Hospitalization only if no improvement or condition deteriorates

Management of Grade 3
ulcer
Requires hospitalization
Surgical debridement
Send tissue, pus and bone C&S
Bone HPE (gold standard for Osteomyelitis)

Wound Care
IV Antibiotic treatment
Mild to moderate for 1-2 weeks, severe for >2 weeks
Osteomyelitis for at least 6-8 weeks
Change antibiotic treatment depending on culture results
Oral antibiotics at home once stable

Management of Grade 4 & 5

Ulcer
Urgent hospital admission and surgical consultations
Requires amputation
Removal of gangrenous parts until viable bones and tissue

obtained
Allow optimum function of the remaining foot

Prevention

Prevention through education

Proper risk assessment
Early and aggressive treatment