Health and Wellness

Diabetic Foot Ulcers

In addition to maintaining close communication with your medical care providers, and cooperating with your doctors’ instructions and treatment plans for any condition, one of the best ways you can protect yourself or a loved one from an untoward medical outcome is to become familiar with the signals pointing to a possible need for urgent medical intervention. With that in mind, we invite you to spend a few minutes familiarizing yourself with medical topics of possible interest. This month’s discussion focuses on Diabetic Foot Lesions.

Diabetes mellitus is a disease that can significantly affect one’s microvascular circulation, particularly in the extremities, where it limits blood supply to both superficial and deep tissues. Pressure from ill-fitting shoes or prolonged contact with bedding or other surfaces can further interfere with blood supply to the extremities, and thus lead to infection. Such infections may involve the skin, soft tissues, bone, or all of these tissues.

Diabetes can also worsen the severity of disease of major blood vessels, and thus add to the negative effects of atherosclerosis and/or peripheral vascular disease. However, most diabetic foot infections occur in the setting of good peripheral pulses. This indicates that the primary problem in diabetic foot infections is reduced microvascular circulation (at the level of the tiny blood vessels) in the extremities. Such impaired circulation keeps white blood cells from reaching areas of infection. This limits the ability of antibiotics to reach the site of infection in helpful concentrations. Diabetic neuropathy (nerve damage) is often part of the diabetic picture as well. This loss of nerve sensation can keep minor foot injuries such as blisters or splinters from being recognized at an early stage. Sometimes diabetic patients go on to develop areas of bone in their feet which become isolated and have no blood supply. Once these areas of bone become infected (osteomyelitis), antibiotics can reach them only via the remaining blood supply. Therefore, it takes surgical removal of dead or infected tissues (debridement), along with antibiotic therapy to help these patients. Patient’s at risk of foot injury due to diabetes may or may not have a history of trauma or previous infection. Often, especially when there is significant diabetic neuropathy (nerve damage), pain may be limited or absent. Foul-smelling discharge from an area of discolored or broken skin c an sometimes be present. With superficial infection (cellulitis), x-ray or other imaging studies are usually not performed. In patients with deep skin and soft tissue infections x-ray, CT scan, or MRI may be used to narrow down the nature and extent of tissue damage. In instances of bone infection (osteomyelitis) x-rays generally show abnormalities after 10-14 days. Bone scan can be used to rule out osteomyelitis much earlier, but are usually not necessary unless there is diagnostic confusion between possible bone infection vs. a bone tumor. Antibiotics and surgical debridement are the mainstays for treatment of diabetic foot lesions. Surgical debridement in chronic osteomyelitis is the single- most important form of treatment, and generally speaking the condition cannot be cured without it. In some cases, amputation may be required. If amputation is performed, physical therapy and rehabilitation may be started on an inpatient basis and completed on an outpatient basis. The outlook for diabetic patients with foot lesions, including soft tissue and/or bone infections depends on prompt and effective antibiotic treatment and surgical debridement as indicated. For cases of bone infection, outcomes are directly related to the condition of circulation in the affected limb and the adequacy of surgical debridement. For diabetic patients at risk of developing foot lesions, avoidance of injury through care in selecting non-pinching or otherwise irritating footwear and close attention to the feet during periods of immobility due to hospitalization or injury are among the best ways to prevent development of serious infections. In addition, regular close inspection of the feet by your primary care doctor, and by yourself or a family member or friend between medical appointments can help spot trouble before an infection develops or becomes difficult to treat. Once foot lesions develop and become infected, early recognition of a developing infection is the best way to ensure a favorable outcome. The longer treatment is delayed the more tissue destruction will occur, and the more difficult the infection will be to treat. Delayed treatment will almost always cause harm and disability to the patient.

In general, diabetics with foot infections should be treated aggressively, often requiring admission and consultation with surgeons and infectious disease consultants. If you suspect that you or a loved one may be suffering from or at risk of developing a foot lesion or infection, visit your primary care provider as soon as possible and ask them to explain their plan for prompt and effective treatment, including antibiotic coverage and removal of dead or infected tissue if warranted. If your doctor tells you that you are suffering from osteomyelitis, insist on an aggressive plan of treatment through surgical debridement and antibiotic therapy. While the majority of health care provided at hospitals and clinics across the United States meets world-leading standards for thoroughness and competence, avoidable mistakes still do occur.

If you believe that you or a loved one has suffered from negligent medical care in the course of treatment by government health care providers, including the VA and military services, then the attorneys of Rawls & McNelis, P.C. are prepared to assist you. Please return to our home page for instructions on how to contact our firm for a no-cost evaluation of your case.