When A Blister Becomes An Ulcer: The Perils Of Insufficient Testing

Author(s): 
By Babak Baravarian, DPM

There is a great deal of satisfaction when our diabetic foot care team gets referrals for patients who were previously seen by doctors from surrounding regions and other nations. However, there is also a great deal of difficulty with poorly or improperly managed cases. In this diagnostic dilemma, I’d like to focus on one patient who was sent to us after one year of care by several doctors.
The patient in question is a 70-year-old male, who was previously seen by two podiatrists and an orthopedist. His initial complaint was a small blister plantar to the first metatarsal head of his left foot. He had just returned from a business trip in which he had done excessive amounts of walking. Near the end of the trip, he noticed the blister and followed up with his local podiatrist two days later. The blister had ruptured when he saw the podiatrist and evolved into a small eschar with dry blood covering the site.
The patient has had diabetes for 20 years that he has controlled with oral medication. He also has peripheral neuropathy of the feet to the ankle. Pulses were not palpable but the foot was warm to touch and the capillary fill time was five seconds. His foot type was a high arch foot with a plantarflexed first ray and a mild equinus deformity. His doctor debrided the local wound and noticed minimal bleeding. He started wet to dry dressing changes and told the patient to wear only tennis shoes for the next week.
At one week follow-up, the patient’s foot was warm and swollen, and the blister had become an ulcer. There was edema locally at the first metatarsal head region, yet there was no drainage. The patient was complaining of mild pain and difficulty sleeping. The doctor debrided the wound of necrotic borders and started levofloxacin for antibiotic care. He instructed the patient to call if he got fever or chills, and to continue wet to dry dressing changes.
The patient in question is a 70-year-old male, who was previously seen by two podiatrists and an orthopedist. His initial complaint was a small blister plantar to the first metatarsal head of his left foot. He had just returned from a business trip in which he had done excessive amounts of walking. Near the end of the trip, he noticed the blister and followed up with his local podiatrist two days later. The blister had ruptured when he saw the podiatrist and evolved into a small eschar with dry blood covering the site.
The patient has had diabetes for 20 years that he has controlled with oral medication. He also has peripheral neuropathy of the feet to the ankle. Pulses were not palpable but the foot was warm to touch and the capillary fill time was five seconds. His foot type was a high arch foot with a plantarflexed first ray and a mild equinus deformity. His doctor debrided the local wound and noticed minimal bleeding. He started wet to dry dressing changes and told the patient to wear only tennis shoes for the next week.
At one week follow-up, the patient’s foot was warm and swollen, and the blister had become an ulcer. There was edema locally at the first metatarsal head region, yet there was no drainage. The patient was complaining of mild pain and difficulty sleeping. The doctor debrided the wound of necrotic borders and started levofloxacin for antibiotic care. He instructed the patient to call if he got fever or chills, and to continue wet to dry dressing changes.
The patient returned the following week with no erythema or edema of the ulcer site. However, he did have an increase in pain and continued necrotic skin edges. The ulcer had become full thickness with penetration of the subcutaneous fat and palpable flexor tendon. His local podiatrist took radiographs that showed no bone involvement and the patient received pain medication for his nighttime pain complaints.
This process of weekly visits continued with no change in treatment and a continued increase in the size and depth of the ulceration for the next two months. At two months, the patient went to a local orthopedist for a second opinion. He suggested a hallux amputation to close the ulcer. He thought the ulcer was deep and probed to bone and suggested treatment with removal of any infected bone.

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