Foot Ulcers: Objectives
• Discuss the work-up and treatment of
common foot ulcers
Clinical Scenario
• A 56 year old man with history of
uncontrolled diabetes, diabetic
neuropathy, lower extremity peripheral
artery disease, venous insufficiency,
and recent immobility following a stroke
presents with a foot ulcer
• How do you work-up and treat this foot
ulcer?
Work-up
• Determine extent of the ulcer: If osteo
suspected, get imaging (e.g. MRI) and if
applicable, bone biopsy for culture
• Note: Fever/chills/leukocytosis may not
always be present with soft tissue infxn
or osteomyelitis
Treatment
• Moist or dry dressings on clean, granulating
tissue with/out topical antibiotics
• No skin cleansers or antiseptics (Hydrogen
peroxide or Betadine) as it destroys
granulating tissue
• Skin grafting (Plastics) may be needed for
large ulcers
• Wound debridement and systemic antibiotics
may be necessary if associated cellulitis or
osteomyelitis
Treatment
• Identify and treat the underlying cause
of the foot ulcer
• Common underlying causes of foot
ulcers: Arterial insufficiency, neuropathy
(e.g. diabetic), venous stasis, pressure
Treatment
Characteristics Treatment
Arterial
Insufficiency
Physical exam clues include
absent pulses, pallor on elevation
of foot, dependent rubor, delayed
capillary return, thickened nails,
absence of toe nails
Reconstruction or bypass of
affected arteries often needed
Neuropathic/
Diabetic
Damage to various types of
sensory fibers lead to loss of
protective sensation; motor
neuropathy may lead to gait
disturbances and repetitive insults
(Charcot foot deformity of DM)
Treat underlying cause, such as
diabetes for diabetic neuropathy;
Physical therapy, orthotics, shoe
inserts may be necessary for
associated gait abnormalities
Venous stasis
Ulcer often occurs in supra and
peri-malleolar regions. Often
associated with prior DVT or
primary valvular incompetence
leading to venous hypertension
Treatment includes compression
devices and possibly surgery
Pressure
Constant pressure applied to body
surface (usually over bony
prominence) may cut off blood
supply leading to ulceration
Scheduled rotation of immobilized
patients and use of cushions to
prevent pressure ulcers
Summary
• When evaluating a foot ulcer: determine
the extent of disease, treat the ulcer,
and treat the underlying cause of the
ulcer to promote healing and prevent reoccurence
Resources
• Sumpio BE. Foot Ulcers. N Engl J Med. Sept 14
2000;343(11):787-793
• Angie N, Bergan J. Chronic Venous Ulcer. BMJ.
April 5 1997;314(7086):1019-1023
• Bluestein D, Javaheri A. Pressure Ulcers:
Prevention, Evaluation, and Management. Am
Fam Physician. Nov 14 2008;78(10):1186-1194