Mal Perforans Ulcer

The patient 74 year old divorcee who lives alone.  He is an insulin-dependent diabetic with peripheral neuropathy.  He has had a plantar ulcer for > 6 months that began after a callosity was pared down by a podiatrist.  He has been seen at a wound care clinic for six months where dressings are done.  He is afraid he may lose his foot.

O/E:  On the plantar aspect of the left foot, he has a clean. painless ulcer measuring about 1.4 cm in diameter.  There was a thick callosity the ulcer's periphery.  His pedal pulses are strong.


Clinical image:

Question:  How would you approach this ulcer?

6/15/2018
The patient had an orthopedic procedure two months ago.  This was intended to  redistribute some of  the pressure on the ulcerated area.  It was quite successful.  He has some mild foot edema presently, but the ulcer has healed completely.  His A1C is normalizing, too.

                         

Reference:

Lu SH, McLaren AM. Wound healing outcomes in a diabetic foot ulcer outpatient clinic at an acute care hospital: a retrospective study. J Wound Care. 2017 Oct 1;26(Sup10):S4-S11

Abstract

OBJECTIVE: Patients with diabetic foot ulcers (DFU) have an increased risk of lower extremity amputation. A retrospective chart review of patients with DFUs attending the Foot Treatment and Assessment chiropodist-led outpatient clinic at an inner-city academic hospital was conducted to determine wound healing outcomes and characteristics contributing to outcomes.

METHOD: We reviewed the complete clinical history of 279 patients with 332 DFUs spanning over a five-year period.

RESULTS: The mean age of patients was 61.5±12.5 years and most patients (83.5%) had one DFU. The majority of wounds (82.5%) were in the forefoot. Overall, 267/332 (80.5%) wounds healed. A greater proportion of wounds healed in the forefoot (82.5%) and midfoot (87.1%) than hindfoot (51.9%; p<0.001). Using a logistic regression model, palpable pedal pulse and use of a total contact cast were associated with better wound healing.

CONCLUSION: Our findings are the first to demonstrate the benefits of chiropodists leading an acute care outpatient clinic in the management of DFUs in Canada and delivers wound healing outcomes equivalent to or exceeding those previously published.

  

Traumatic Ulcer

Abstract: 40 year-old man with non-healing wound

HPI: The patient is a 40 yo man who sustained traumatic abrasions of his leg and arm from a motorcycle accident on May 31, 2011. He has a history of chronic vesicular dermatitis of hands and feet complicated by recurrent staphyloccal cellulitis of legs. The wound on his right knee became infected and he was hospitalized over the summer on two occasions for parenteral antibiotics and debridement. As a result of this wound he has lot his job and his family is living marginally.

O/E: September 14, 2011. There is a nine cm relatively clean ulcer over the right knee. It has shown no tendancy to heal over the past month.

Clinical Photograph:

Diagnosis: Ulcer right knee.

Questions: How would you approach this lesion so that the patient can heal and get back to work? At present, he is getting dressing changes a few times a week and there are no plans for further surgical interventions. It looks like this will take months to heal by secondary intention.

Follow-Up: 10/19/2011 I have seen the patient on two occasions since this posting. The ulcer is ~ 75% better with just daily dressing changes with Vaseline impregnated gauze. He has not needed any further antibiotics. I expect it will be completely re-epitheliazed in two to three weeks.