How To Manage Heel Ulcers In Patients With Diabetes

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Continuing Education Course #128 — March 2005

I am pleased to introduce the latest article, “How To Manage Heel Ulcers In Patients With Diabetes,” in our CE series. This series, brought to you by the North American Center for Continuing Medical Education (NACCME), consists of regular CE activities that qualify for one continuing education contact hour (.1 CEU). Readers will not be required to pay a processing fee for this course.

Given the prevalence of heel ulcerations and the potential for serious complications in the diabetic population, Jonathan Moore, DPM, and Pamela Jensen, DPM, offer an algorithmic approach to diagnosing and managing these ulcerations. They emphasize a multidisciplinary approach and the importance of evaluating the entire patient and relevant comorbidities in order to facilitate successful outcomes.

At the end of this article, you’ll find a 10-question exam. Please mark your responses on the enclosed postcard and return it to NACCME. This course will be posted on Podiatry Today’s Web site (www.podiatrytoday.com) roughly one month after the publication date. I hope this CE series contributes to your clinical skills.

Sincerely,

Jeff A. Hall
Executive Editor
Podiatry Today

INSTRUCTIONS: Physicians may receive one continuing education contact hour (.1 CEU) by reading the article on pg. 91 and successfully answering the questions on pg. 98. Use the enclosed card provided to submit your answers or log on to www.podiatrytoday.com and respond via fax to (610) 560-0502.
ACCREDITATION: NACCME is approved by the Council on Podiatric Medical Education as a sponsor of continuing education in podiatric medicine.
DESIGNATION: This activity is approved for 1 continuing education contact hour or .1 CEU.
DISCLOSURE POLICY: All faculty participating in Continuing Education programs sponsored by NACCME are expected to disclose to the audience any real or apparent conflicts of interest related to the content of their presentation.
DISCLOSURE STATEMENTS: Drs. Moore and Jensen have disclosed that they have no significant financial relationship with any organization that could be perceived as a real or apparent conflict of interest in the context of the subject of their presentation.
GRADING: Answers to the CE exam will be graded by NACCME. Within 60 days, you will be advised that you have passed or failed the exam. A score of 70 percent or above will comprise a passing grade. A certificate will be awarded to participants who successfully complete the exam.
TARGET AUDIENCE: Podiatrists.
RELEASE DATE: March 2005.
EXPIRATION DATE: March 31, 2006.
LEARNING OBJECTIVES: At the conclusion of this activity, participants should be able to:
• assess potential etiologies of heel ulcers in patients with diabetes;
• discuss how nutrition affects wound healing;
• describe the importance of vascular testing and how it impacts diagnosis and treatment;
• discuss key treatment considerations for ischemic heel ulcers;
• discuss an algorithmic approach to managing infected heel ulcers; and
• list steps one can take to prevent ulceration to the contralateral limb.

Sponsored by the North American Center for Continuing Medical Education.

Here one can see well-adhered ischemic eschar. The authors used conservative care including topical enzymatic agents until the eschar began to slough around the periphery.
Here is a non-infected, non-ischemic heel ulceration in a patient with diabetic neuropathy. The authors debrided the ulcer and applied a topical growth factor.
Here is a wet ischemic ulcer in a nursing home patient with diabetes. The ulcer was a result of poor nursing care, pressure, neuropathy and immobility.
Diabetic Heel Wounds: An Algorithm For Treatment
Diabetic Heel Wounds: An Algorithm For Treatment  (con''t)
Should You Debride Ischemic Heel Ulcers?
98
Author(s): 
By Jonathan Moore, DPM, and Pamela Jensen, DPM

   Diabetic heel ulcers constitute one of the most frustrating problems for podiatric physicians. Pressure ulcers affect nearly 2 million people each year and account for annual healthcare costs that range between $2.2 billion and $3.6 billion. The heel is the second leading site for development of pressure ulcers after the sacrum.1 While patients with diabetes are living longer than in the past, the incidence of hospital-acquired heel ulcers increased from 19 percent in 1989 to 30 percent in 1993.2

   Costs for heel ulcers are nearly double that of the costs associated with forefoot ulceration.2 Given the higher incidence of osteomyelitis in the calcaneus along with the presence of vascular disease, patients with diabetic heel ulcers present a significant challenge for limb salvage. It is vital to have a thorough understanding of the associated comorbidities that complicate diabetic wounds in order to manage these patients successfully and prevent potential limb loss. Accordingly, a multidisciplinary approach is essential. Initiating appropriate consults and dialogue with vascular surgery, endocrinology and internal medicine is crucial to successful treatment.

Assessing Possible Etiologies

   As part of the preliminary evaluation, one should determine the etiology of the ulcer. The most common contributing factors to the development of diabetic heel ulcers include diabetic neuropathy, immobility, structural deformity, peripheral vascular disease, trauma and age. Additional factors may include shearing/friction, temperature, age, edema and anemia.3

   Diabetic neuropathy is the most critical component in the development of the diabetic ulcer. Whether precipitated by repetitive stress from poor weight distribution or from dyshidrosis and fissuring from autonomic neuropathy, one must assess the presence and extent of neuropathy in order to prevent these types of ulcers effectively.

   A lack of mobility can generate excessive levels of pressure to the skin among older patients and those with deformity or illness. Poor mobility in the presence of edema and/or vascular disease can be a major factor in the development of an ulceration.

   Heel ulcers represent localized areas of cellular necrosis that result from prolonged circulatory interference from pressure or shearing forces. Although pressure is a critical factor involved with skin breakdown, researchers have shown that shearing forces (stretching of blood vessels) compound the ischemic changes produced by external pressure and lead to an increased rate of tissue breakdown.4

   If the heel is subjected to prolonged periods of pressure that exceed capillary pressure, ulceration will result.

   In addition to pressure and friction, the shock absorption in the heel declines with age. The decreased shock absorption contributes to tissue breakdown and increased morbidity. Atrophy of muscle and fat tissues in patients with diabetes has been proposed as one of the possible factors that increases the risk of ulceration. Researchers have determined that heel thickness in non-ulcerated patients with diabetes is 2 mm less than the heel thickness in non-diabetic patients.5 Diabetic patients with a history of ulceration have heel thicknesses 3 to 4 mm less than non-diabetic patients.5

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