Part 3 of a series discussing the assessment and management of lower extremity wounds For Part 1, click here. For Part 2, click here.

In this last of our three-part series on lower extremity wounds, we will focus our attention on diabetic foot/neuropathic ulcers. Research indicates that the United States national average for diabetes mellitus (DM) accounts for a little over 8% of the nation, or roughly over 18 million Americans afflicted with this disease—what the industry refers to "the silent killer" for the amount of damage it causes. DM has the capacity to affect vision and circulation, as well as increase the incidence of stroke and renal disease, just to name a few associated problems. Over 20% of individuals with diabetes will develop ulcerations, with a recurrence rate of over 50% for diabetic foot ulcers (DFUs) alone. Overall, lower extremity wounds have recurrence rate of 40-90%. We have our work cut out for us. So, let's put our deuces up, recognize early intervention, and try our best to manage and prevent complications associated with DM.

Diabetic Foot Ulcers / Neuropathic Ulcer Risk Factors

Contributing factors such as neuropathy, foot deformity, infection, and vascular disease become more prevalent in the presence of DM. These types of wounds are also referred to as neuropathic ulcers. The majority of patients with diabetes will develop neuropathy, but there are some that will have neuropathy without having DM, and therefore are at high risk to develop foot ulcers as well—hence, diabetic foot or neuropathic ulcers. The goal of the SWAT (skin wound assessment team) will always include the family and patient, increase quality of life, and eliminate any amputation by using standards of care, evidenced-based research, and best practices in order to achieve positive outcomes.

Risk Factors for Diabetic Foot Ulcers (DFUs) or Neuropathic Ulcers

• Vascular disease – PAOD, PVD, mixed
• Neuropathy – (sensory) exaggerated pain or lack of sensation, (motor) foot deformities, callous formation, Charcot foot, hammer toes, (autonomic) anhydrosis, lack of sweat, high risk for infection r/t cracked skin – Semmes-Weinstein monofilament test is the Gold Standard
• History of previous DFU/neuropathic ulcers
• Foot deformities/Charcot foot
• Mechanical stress associated with foot deformities
• History of amputations (AKA, BKA, TMA, or Ray amputation of a toe)
• Obesity
• Impaired vision
• Poor glycemic control

Wound Characteristics of Diabetic Foot Ulcers / Neuropathic Ulcers

• Location - Anywhere in the leg, but more common on foot, plantar area and over metatarsal heads
• Even wound margins
• Callous to wound edges – hyperkeratotic rim
• Presence of non-viable tissue is common
• Minimal to moderate drainage
• Bone may be palpable on base of wound
• Presence of foot deformities/Charcot foot
• Mostly round with a deep wound bed
• Not painful due to decreased sensation
• Palpable pulses

Diagnostics

• Doppler studies
• Ultrasound
• ABI
• Transcutaneous oxygen measure
• Semmes-Weinstein monofilament test – neuropathy
• HgAIc
• MRI, bone scan to rule out osteomyelitis

Methods of Classification

• Wagner Classification Scale
• University of Texas Diabetic Wound Classification System

Treatment Options

• Offload – Total contact casting – "gold standard," shoes or splints, custom orthotics
• Local wound care, use of advanced of wound care products
• Debridement – callous, non-viable tissue, and bone if needed
• Management of edema
• SWAT team
• Podiatric or orthopedic consult
• DM management
• Wound bed preparation
• Surgical options if necessary
• Vascular bypass
• Hyperbaric oxygen therapy
• Electrical stimulation
• Growth factors – beclapermin PDGF

Ending Points on Diabetic Foot Ulcer Prevention and Treatment

The use of best practices, standards of care, evidence-based research, and being cost-effective in order to achieve positive outcomes is of utmost importance in the prevention and management of diabetic foot ulcers. Involvement of the SWAT team remains a best practice, and should be second nature. Like always, it takes a village. Let’s teach, coach, and mentor. Let’s give our families and patients the tools necessary for success. Remember: refer to your guidelines and always ask questions.

Statistics indicate that nearly half of all unhealed neuropathic ulcers result in death within 5 years. Furthermore, after 1 major amputation, the three-year survival rate is 50%, and the 5-year survival rate is 40%. Over 50% of patients will have a second amputation within 3-5 years. Dr. Yazan Kahtib couldn’t have said it better (and this has stuck with me for years thanks to Save a Leg, Save a Life Foundation): "Amputation should not be seen as a treatment option, but as a treatment failure."

Clinicians who have chosen to make a commitment to the world of wound management, like myself, go through a roller coaster of emotions. We have laughed, we have cried, and we have yelled to no end when we get the feeling of failure, when we feel we could have done more.

First and foremost, we are passionate caregivers and patient advocates. Like any specialty, we take pride in what we do, and we all want to leave is our footprint or our "two clinical cents" on the table for the greater good. We are challenged by barriers, such as those we encounter in the field of wound management. With that said, I would love to recognize each and every one of you. Pat yourselves on the back. High five each other. Thank you for all your hard work and dedication to this very exciting field of ours.

Keep fighting the good fight.

Keep healing, my friends!

References:
Clinical Guide: Wound Care 4th edition C.T Hess, chapter 5
Wound Management Guide: A comprehensive guide to the wound care clinician, Livingston and Wolvos, p.45-55
Wound Care Certification Study Guide, Shahm Sheffield and Fife, chapter 19

About the Author
Martin Vera is a certified wound specialist with over 19 years of nursing experience, with a passion for wound management and patient-centered care.