Diabetic foot ulcers (DFUs) are ostensibly the most challenging types of chronic ulcerations to manage, given their multifactorial nature. Thorough, systematic assessment of a patient with a DFU is essential to developing a comprehensive plan of care. To implement the treatment plan successfully, clinicians and patients must work together to address each factor contributing to ulcer development and perpetuation.
Historically, classification and subsequent treatment of DFUs do not adequately include management of concomitant ischemia of peripheral arterial disease (PAD). The Wagner Diabetic Foot Ulcer Grade Classification System, which has been in use since its inception in the 1970s, did not have the capacity to describe ischemic components of DFU. The University of Texas Diabetic Foot Ulcer Classification System, PEDIS (perfusion, extent, depth, infection, and sensation), WIfI Threatened Limb (Wound/Ischemia/Foot Infection), and SINBAD (Site, Ischemia, Neuropathy, Bacterial infection, And Depth) are classification systems that utilize degrees of ischemia as a contributing factor.1
At present, subclassification of DFUs can be divided into three categories: neuropathic, ischemic, and neuroischemic. The most prevalent of the three is the neuroischemic DFU, which comprises approximately 50% of such ulcerations.2 Organization and reproducibility of the assessment process are crucial to success. Workups should include identification of intrinsic and extrinsic factors, both modifiable and non-modifiable. We will review appropriate assessments by using a typical history and physical examination format.
History of Present Illness: Clinicians will often have varied processes for obtaining the same information, but using an assessment model that is reproducible will be most useful. OLDCHARTS (Onset, Location, Duration, Characteristics, History of same symptoms, Aggravating factors, Relieving factors, Timing, Symptoms associated) is one example. Some basic questions you should ask your patient are:
Pertinent Medical History and Review of Systems: There is a multitude of comorbid physiologic conditions and contributing factors that negatively affect the healing of DFUs. It is imperative that the patient is managed medically by providers skilled in each specialty respective to the condition being treated (e.g., rheumatologist for autoimmune disease, endocrinologist for metabolic disorders).
Surgical History: Patients with DFUs who have had prior non-traumatic amputation are at greater risk of additional amputation. In addition, patients who have undergone lower extremity vascular procedures may present with atypical lower extremity edema. Moreover, if a patient has a corrective procedure that resulted in resolution of an ulceration, and the same phenomenon occurs on the contralateral limb, it is of great clinical importance to note this in the history because the patient may benefit from repeating the procedure on the affected side.
Medications: A plethora of medications may affect the healing of DFUs. Patients taking insulin have higher rates of wound healing overall.3 Most other medications to be cognizant of are those that delay healing such as anti-inflammatory drugs; their use on a short-term basis can be beneficial, but in the long term they can be a barrier to healing.
Social History: This portion of the history and physical examination is sometimes overlooked as pertinent to the patient’s overall condition. The patient’s health literacy level should be catered to because interventions that patients do not fully comprehend are far less likely to be followed. The patient should be counseled regarding resources if any gaps in care are encountered (e.g., if the patient does not have running water, referral to case management to seek assistance programs for utilities, etc., may be warranted).
A thorough physical examination will reveal an abundance of useful clinical information. The information garnered will allow for appropriate grading and classification of the DFU, by providing prognostic value and guiding treatment. Some information in the examination may even reveal undiagnosed conditions impeding the healing process (e.g., lower extremity swelling despite adequate elevation and compression may indicate the need for a cardiology referral).
These data, in isolation, are not always clinically useful. Combining these data with the medical history and physical examination data will further clarify the clinical picture of the patient with a DFU. At times, the data will show a positive correlation (e.g., the wound assessment reveals positive probe to bone, and erythrocyte sedimentation rate [ESR] is 85). Conversely, it may reveal a negative correlation (e.g., the patient may have normal white blood cell (WBC) count, but wound assessment reveals erythema and a purulent, malodorous exudate).
Accurate assessment and classification guide treatment and provide prognostic information for the patient’s course of care. The goals of assessment should include identification and stratification of risk for progression of ulceration and propensity for development of infection and to confirm the diagnosis by ruling out other etiologies that may require different interventions. Assessment of detailed patient history, disease status of DM including glucose control and medication management, other comorbid conditions, functional status and ability to perform ADLs, social habits such as tobacco use and alcohol intake, and socioeconomic status and health literacy are inherently valuable to forming a comprehensive treatment plan.
1. Schaper NC. Diabetic foot ulcer classification system for research purposes: a progress report on criteria for including patients in research studies. Diabetes Metab Res Rev. 2004;20 Suppl 1:S90.
2. Chadwick P, Edmonds M, McCardle J, Armstrong D Best Practice Guidelines (IBPG): Wound Management in Diabetic Foot Ulcers. Wounds International. 2013. http://www.woundsinternational.com/best-practices/view/best-practice-gu…. Accessed August 6, 2018.
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4. Sheehan P, Jones P, Giurini JM, et al. Percent change in wound area of diabetic foot ulcers over a 4-week period is a robust predictor of complete healing in a 12-week prospective trial. Plast Reconstr Surg. 2006;117:239S.
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7. Khodaee M, Lombardo D, Montgomery LC, Lyon C, Montoya C. Clinical inquiry: what’s the best test for osteomyelitis in patients with diabetic foot ulcers? J Fam Pract. 2015;64(5):309–310, 321.
8. National Diabetes Education Program (NDEP). Feet can last a lifetime: a health care provider’s guide to preventing diabetes foot problems. National Diabetes Education Program. 2000. http://www.algadam.net/images2/Guide-PDF%20%282%29.pdf. Accessed August 6, 2018.
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, HMP Global, its affiliates, or subsidiary companies.