Current Concepts In Diagnosing Chronic Diabetic Foot Ulcerations

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What About Chronic Venous Stasis Ulcerations?

When patients report their history in a particular way, one can suspect chronic venous stasis ulceration. Often, this description will include discomfort that patients report as a deep aching sensation within their legs.

• “I had to stop wearing my compression stockings because they were making my legs swell.”
• “I just began noticing drainage on my stockings.”
• “I noticed water blisters on my legs but did not know what to do about them. Now I have sores on my legs that just will not heal.”

Fluid retention within the legs, ankles or feet is a hallmark of this condition. The pathomechanics for venous ulcer development includes inflammation that stimulates leukocyte activation, endothelial damage, platelet aggregation and intracellular edema. That sounds an awful lot like the mechanism for blood clot formation. Among the risk factors for venous ulcer development are older age, obesity, previous leg injuries, deep venous thrombosis and phlebitis.

In this instance, the chronic condition is venous stasis, not necessarily the ulceration. Often occurring on the medial ankle and associated with chronic pain, venous stasis ulcerations require therapy to address the wound as well as mechanisms to address fluid retention in the limb to reverse the process successfully. At times, the medical team employs medications to encourage diuresis when appropriate.

The use of compression hose is the mainstay in long-term management of venous stasis ulcers. Often, these modalities range from 20 mmHg compression to 30 mmHg compression. While elevation, the use of compression hose and local wound care can be effective, the risk and rate of recurrent ulceration is a reality. Researchers have demonstrated that surgical correction of superficial venous reflux reduces 12-month ulcer recurrence.46 In that study, the authors concluded that most patients with chronic venous stasis ulcerations will benefit from simple venous surgery. This conclusion was evident in the fact that 12-month ulcer recurrence rates were significantly reduced in the compression hose and surgery group in comparison to compression therapy alone (12 versus 28 percent).

With this in mind, I cannot overstate the importance of getting a vascular surgery consultation in the case of chronic venous stasis complicated by ulceration. Considering the data that 1 to 2 percent of the population will suffer from chronic venous ulceration, delayed healing times and increased incidence of recurrence are predictable.47,48 Recurrence rates are reportedly as high as 26 to 28 percent and one study reported a 68 percent recurrence rate.46,48-51 As many as 10 percent of the U.S. population may suffer from valvular incompetence in the venous system and 0.2 percent of those patients may develop an ulceration.52 It is understood that recurrent ulceration may occur in as many as 70 percent of those at risk.52

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Molly Judge, DPM, FACFAS

Offering pearls from the literature as well as her clinical experience, this author discusses the impact of infection, reviews common diabetic dermatopathology and notes other pertinent diagnostic keys.

Beginning with the initial patient presentation, there are a number of keys to manage chronic diabetic foot ulcerations. The first of these is the ability to make a definitive diagnosis.

   When a patient reports to the office with a concern about pre-ulcerative or ulcerative conditions, it is critical to determine the etiology of the condition and make an accurate diagnosis. To some, this may sound overly basic but it is not uncommon for a patient to report being treated for a prolonged period of time and never getting any better.

   Often when patients are asked if they received a diagnosis, they say the doctor told them they had an ulcer and that was the extent of the diagnosis. When asked about the plan for home care, patients often say they only got instructions to put antibiotic ointment and a bandage over the ulcer. Other patients will ask rhetorically, “What home care?”

   About 2.5 percent of patients with diabetes develop foot ulcers each year and foot ulcers are the most common cause of hospitalization for the patient with diabetes.1 Furthermore, 15 percent of diabetic foot ulcers result in amputation of the foot or leg.2

   Given these statistics, clinicians need to strive for an accurate, timely diagnosis, determining specific wound measurements and quickly beginning an aggressive wound management program. This typically includes the benefit of baseline radiographs and ancillary imaging when indicated. At the beginning of wound care planning, one should consider offloading the limb, systemic conditions such as enhanced glycemic control, dietary adjustments and neurovascular testing among other factors.

   When there is no suspicion of infection, the need for blood work becomes debatable. Baseline serologic testing may include complete blood cell count (CBC), C-reactive protein (CRP) and a complete metabolic profile as these patients often do not present regularly (if ever) for care by an internist. When treating a wound over time, there may come a point where the wound progress stalls or one suspects infection. At this point, it may be regrettable that one did not perform baseline serologic screening as neutropenia and hematologic imbalances can influence a patient’s ability to mount a sufficient immune response to infection. This is particularly true in the patient with diabetes.

Recognizing Acute, Chronic And Mechanical Wounds

The history of the condition will often shed light on the etiology. For instance, certain chief complaints often correlate with the etiology of the ulcerative condition.

   One must differentiate acute wounds from chronic wounds as they have a different prognostic potential. An acute wound caused by trauma breaks down intact skin. These wounds should have a predictable timetable to healing that correlates with the nature and extent of the injury. Acute injuries as a result of surgery, trivial trauma (abrasions, contusions) or otherwise (gunshot wounds or burns) often have a clinical course in healing that is predictable once the wound has become fully apparent.

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