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

   An acute wound caused by trauma breaks down intact skin. These wounds should have a predictable timetable to healing that correlates with the nature or extent of the injury. Injury as a result of surgery, trivial trauma (abrasions, contusions) or otherwise (gunshot wounds or burns) often has a clinical course in healing that is predictable.

Diagnosing Arterial Ulcerations

Arterial ulceration (ischemic ulceration). Suspect an arterial ulceration when the history includes the onset of pain in association with the development of a sore or ulceration in an unusual location. One may hear patient variations on the following statements.

• “I noticed pain and a sore developing on the outside of my ankle or the tips of the toes.”
• “I noticed a chunk of skin was missing from the outside of my leg” (a punched out appearance).

Final Recommendations

When considering chronic ulcerations, it is often difficult to determine exactly when to shift gears in therapy. Knowing when to say when in using simple in-office local wound care methods is important to successful patient management. After all, in-office wound care can be very time consuming. When the physician becomes overwhelmed with the time, amount of supplies and equipment that are required to handle chronic wounds, it is easy to lose sight of just how long this wound care program has been going on. After all, getting the patient into the room, documenting the subjective information and then providing the patient care (debridement, irrigation, application of dressings and detailed patient education) usually takes more time than the schedule typically allows.

   The last thing to consider is the duration of the ulcer. It is common to have a patient with an ulcer returning with great frequency and the patient allowing this therapy to go on indefinitely rather than making an alternate decision that might not include limb salvage. But how long can a patient continue to care for an ulceration and have the physician document the wound as having a “very good clinical appearance and healing well”?

   In 2003, Sheehan and colleagues considered this point and conducted a study to determine just how much wound healing was considered sufficient to predict successful definitive wound healing.45 The purpose was to assess the four-week healing rate as an indicator of healing within 12 weeks in foot ulcers in patients with diabetes. This study focused on 203 patients with ulcerations that had been present for 12 weeks. What they found was that when a wound’s area was reduced by greater than 53 percent at four weeks, it was not just a good indicator but a robust indicator that the wound could heal by the 12-week mark. This study supplied physicians with a very good rule of thumb when dealing with chronic wounds and enabled prognostication to include the estimated time to healing.

   Shifting gears in a wound care plan typically includes ancillary imaging, tissue and/or bone biopsy. When advancing the care plan in a more aggressive direction, the use of grafting and specialized tissue membrane transplants often has a role. From a common sense perspective, there are a number of traditional rules of thumb in wound care that have truly withstood the test of time and these include topical agents geared at improving the quality of skin, reducing bacterial colonization and ridding the wound bed of fibrous ingrowths. The table at left provides a summary of some effective common agents that can be of benefit in day-to-day wound care strategies.

   This article is meant to provide basic practical information regarding wound care in the patient with diabetes, which can be an arduous task. There are four fundamental concepts to bear in mind when diagnosing these ulcerations.

1. Whenever possible, make a definitive diagnosis in the very first patient encounter as this allows the patient to more fully understand the course of therapy.

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