Chapter 220: Neuropathic Ulcer

PATIENT STORY

A 52-year-old man with type 2 diabetes, with a history of a third-toe amputation, presented with a new neuropathic ulceration to the right foot (Figure 220-1). The patient recalled having a callus for several months. He noticed blood on his sock a few days ago. He denied fever or chills, but noted that his glucose has been higher than normal. The patient demonstrated loss of protective sensation, but his vascular status was intact. He was referred to a podiatrist who immediately offloaded his foot with a total contact cast. His ulcer healed in 1 month, and he was subsequently fitted with extra-depth shoes.

INTRODUCTION

Foot complications in patients with diabetes mellitus are common, costly, and affect quality of life. Neuropathic ulcers can lead to the most devastating outcome, which is an amputation. Eighty-five percent of all amputations related to diabetes are preceded by an ulcer. Prevention, early recognition, and treatment of foot ulcers are critical in avoiding infections and amputations.

EPIDEMIOLOGY

• Of people with diabetes, 15% will experience a foot ulcer during their lifetime, and 15% to 60% of these will develop osteomyelitis.¹

• Neuropathy causes approximately 50% of diabetic foot ulcers.²

• The prevalence of neuropathic ulcer is 20% in patients with diabetic neuropathy.

ETIOLOGY AND PATHOPHYSIOLOGY

• Peripheral neuropathy is the most important factor in the development of a diabetic foot ulcer.

• Neuropathy causes loss of protective sensation. Also, autonomic neuropathy can lead to anhidrosis, which leads to skin fissuring.

• Moderate pressure with repetitive trauma occurs in a particular site, often from poorly fitting footwear, which then leads to ulceration.

RISK FACTORS

• Diabetic neuropathy increases the risk of developing a foot ulcer by 70%.³

• Patients with pedal deformity combined with diabetic neuropathy are 12 times more likely to develop a foot ulcer.³

• Patients who have a history of ulcerations are 36 times more likely to develop another ulcer.³

• Limited joint mobility, high level of activity, and poorly fitting footwear also increase the risk of the repetitive trauma that leads to ulceration.

• Puncture wounds may become neuropathic ulcers in the presence of neuropathy.

DIAGNOSIS

The diagnosis of neuropathic ulceration is made clinically.

CLINICAL FEATURES

• A red, granular wound base (Figures 220-1 and 220-2).

• Surrounding hyperkeratosis with white, macerated margins (see Figures 220-1 and ...