Current Concepts In Diagnosing Chronic Diabetic Foot Ulcerations

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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