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foot in hand

Here is a slide presentation with excellent information about Diabetic Foot Ulcers.

Diabetic Foot UIcer Overview

“You have a hole in your foot!”  That is usually how I start my discussions regarding Diabetic foot ulcers with a new patient.  There is not supposed to be a hole in your foot.  The fact is, there are things outside of our body that we want to keep out, and skin is our only line of defense in this regard.  Healing a break in your skin, known as a wound or ulcer/ulceration, as fast as possible, is important to restore your defenses against the outside world.

There are more than 3000 specialized products for “wound care”.  Needless to say there is a lot of confusion when it comes to choosing the most appropriate wound care dressing.  Since I teach students and residents, I am forced to keep things simple.  I have a way of describing wounds that is very simple, but allows me to chose a product that fits the characteristics of your ulceration in order to heal.  Wounds, no matter where they are on your body, will fit into one of these three categories.  A wound can be wet, moist, or dry.

Wet Wounds:

Having a break in your skin will result in inflammation, which is the first step in healing.  You must progress past inflammation in order to heal, but diabetic foot ulcers are well known for getting stuck in an endless loop of inflammation.  With the inflammation comes fluid draining from the opening.  A small amount of clear, watery or slight blood-colored drainage is normal, but when this becomes excessive there are problems.  Think of your skin when you spend time in a pool.  Your fingers prune, right?  This is known as maceration and when it happens on the edges of an open wound you have further weakened that skin’s resistance to injury and infection.  Obviously infection can cause increased drainage and antibiotics are part of the answer, but only after testing the wound for infection.  Remember, no cotton swab, testing it has to be a tissue specimen (see Diabetic Ulcer Treatment).

Products used to bandage wet wounds must be able to absorb fluid to get it away from the skin edges and base of the wound. Adding more moisture is a common mistake.  We do not use creams, ointments, salves, coverings that lock in moisture such as Band-aids.  Foams, alginates, even gauze will absorb and move fluid away from the ulcer.

Dry Wounds:

The opposite end of the spectrum is a dry wound.  How often have you heard, “leave it open to the air so it will dry out and form a scab”?  Would it surprise you to know that this was found to be false in 1962?  It takes 100 times longer to heal a wound when scab forms, but even some naïve physicians tell patients that the wound needs air.  The first concern with a dry wound is your circulation.  Once I have done testing to assure that you have adequate circulation to heal or sent you to a vascular surgeon to have circulation repaired, I have to find a product that donates moisture to the wound. 

Moisture donating products are creams, gels, gel sheets…basically if the product is moist then it is able to donate that to the wound.  Ointments are generally not used since these are petroleum based and the petroleum has been shown to reduce the ability to heal.  Science is always changing and there are rare ointments that are not based on petroleum, but just to be safe I recommend you avoid all ointments.  Dry wounds have the problem of that scab forming.  In order to drive the moisture through the dry wound bed, I often add a layer to keep air out.  There are films, barriers, hydrocolloids, and fancy combination dressings that I often add when treating dry wounds.

Moist Wounds:

A moist wound is a healing wound!  Everything above has involved making a wound moist.  We dry a wet wound until it is just moist, we moisten a dry wound.  Keeping the wound moist involves moisture donating products such as gels, creams, and gel sheets.  There is no need to lock in the moisture using a film like I do in dry wounds.  Usually just a gauze covering will suffice.

That’s it.  You have now been given the same information I give my students and residents minus all the fancy names of specific products.  If you have a diabetic foot ulcer or wound and need care, instead of letting someone who is confused about wound care products roll the dice and choose whatever product the last drug rep brought in, come see me at Desert Foot Surgeons.  Your feet matter to us!

Diabetic foot ulcers are serious!  Foot wounds account for the most days missed from work, more hospital days, and the most amputations of any other disease in the world.  Has a doctor ever told you that it just takes longer to heal because you have Diabetes?…False!!…You need to leave it open to the air in order to dry out and make a scab?…False!!…Antibiotics are needed to heal that ulcer?….False!!

There are 3 things needed in order to heal a wound no matter where on your body that ulceration is located.  You might think I’m crazy, but if you came to this website because you heard of me, than you also know that I am best known for my ability to heal foot ulcers.  I know, shocking ..you were thinking it was my glowing personality or good looks, right?  My own mother wouldn’t even say that.  I am matter-of-fact, no hidden agendas type of guy.  You need to know these 3 things needed to heal because it could save your leg.

The 3 Things Needed to Heal Any Ulcer:

  1. You need to have no infection
  2. You must have adequate circulation to heal
  3. There must be no pressure on the ulceration

No Infection:

Infection is when bacteria from your skin, yes from your own skin, travel into the open sore and start to grow.  The reason I mention that the infection comes from your own skin is that treating your wound with antibiotics is not the answer.  If you are infected, you need antibiotics, but not every wound is infected.  Signs of infection include redness that does not turn white when you push on it with your finger, swelling, puss, and sometimes but not always pain.  I diagnose infection by cutting out a small sample from the base of the wound after it has been thoroughly cleansed and submitting that for testing to see if bacteria are present.  Using a cotton swab is not appropriate and leads to unjustified antibiotic use.  There are no strict guidelines on the length of time you need to take antibiotics.  In general for skin infection it is 10-14 days and for bone it takes much longer.  Surgery may be needed to clear infection from your wound.

Adequate circulation:

When we talk about your ability to heal we talk about the blood supply in your arteries.  Peripheral vascular disease in patients with Diabetes is extremely common.  If you smoke and have Diabetes, you are guaranteed of having peripheral arterial occlusive disease otherwise known as poor circulation.  I can’t trust my ability to feel pulses in your feet because that is too subjective.  Any doctor treating wounds will have a hand-held Doppler, which is a miniature ultrasound-like machine that allows us to listen to your circulation.  Veins sound different from arteries and a blocked artery has different degrees of sounds.  That is just basic screening done when I first see you.  Other tests are often needed and will be arranged for you.  Like I said above, I am have no hidden agenda and am very matter-of-fact.  I have a team of physicians I use when circulation is questionable.  I would like you to use these physicians because I have success when my patients see them.  I’m sure your vascular surgeon is very competent, but that doesn’t mean they treat patients with foot ulcers.  More often than not, I end up sending you to my team physicians after you have seen your favorite doctor and circulation has not been restored.

Pressure relief:

Without getting into too much detail there are 3 forces of pressure subjected to a wound no matter where it is on your body.  Let’s keep it to the foot for this discussion.  Vertical load is the pressure of your body weight on the foot ulcer.  Friction is your skin sliding across a surface.  Shearing is when your skin stays still, but the deeper layers move.  Each of these types of pressure cause different signs so I can judge if they are still present despite my best efforts.  Vertical load causes callous to form.  Friction makes blisters.  Shearing breaks blood vessels below the skin and causes bruising or dark discoloration.  The most effective way to relieve all 3 of these forces is total contact casting.  This is a specialized cast enclosing your entire foot to just below your knee.  When total contact casting is used, you will be able to walk on the cast.  Anything other than total contact casting is a compromise.  I will allow you to make compromises in pressure relief in order to live your life the way you need to, but if the foot ulcer gets worse there will need to be a change.

 

Just 3 things to save your foot!  It’s not easy to achieve all three of these, but if you come to Desert Foot Surgeons, it won’t be for a lack of trying.