DIABETIC ULCERS / NON HEALING ULCERS

Non-Healing Wound / Ulcers

Diagnosis/Definition

Chronic Wound: Any non-healing wound and/or ulcer that has been present for 3-4 weeks duration and has not responded to conventional therapies.

Complex Wound: Wound in an area that is difficult to perform wound care, unusual wounds of unknown etiology or wounds that require advanced wound care treatment modalities for example the Wound VAC.

Initial Diagnosis and Management

Pressure Ulcers: Management involves assessment of systems, wound assessment and management, off loading with a specialty bed and evaluation by a plastic surgeon for Stage III or IV ulcers
Stage III - full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend to, but not through, fascia.
Stage IV - full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (tendon, joint capsule).
Non-Healing Surgical Wounds: Wounds that are taking longer to heal because of underlying problems such as diabetes, poor nutritional status, immune compromised, or infection. Any surgical wound of 3-4 week duration that is not responding to conventional therapies. Management includes assessment of systems, wound management, and evaluation of a general surgeon.
Lower Extremity Ulcerations: Any non-healing ulcer of a lower extremity that has been present for 3-4 week duration and has not responded to conventional therapies. The wounds may be arterial, venous, mixed ulcers or pressure ulcers in diabetic patients.
ARTERIAL ULCER - caused by ischemia; related to the presence of arterial occlusive disease; generally present on the foot, typically the distal appendages; very painful; onset can be precipitated by trauma. Management involves assessment of blood flow to the extremity, wound management, and evaluation by a vascular surgeon.
VENOUS STASIS ULCER - result of edema and impaired venous return; loss of epidermis and various levels of dermis and subcutaneous tissue occurring on the medial or lateral aspect of the distal 1/3 of the lower extremity. Often found in combination with an edematous and indurated lower extremity. Management involves assessment of venous system with a venous duplex scan, wound management, compression stockings and/or wraps, and evaluation by a vascular surgeon. If pedal pulses are not palpable, an evaluation of the arterial system should be performed prior to initiating compressive therapy. A dermatologist consult may be obtained if chronic dermatitis is present.
MIXED VESSSEL (ARTERIAL AND VENOUS ULCER) - presence of arterial insufficiency and venous disease. Typically, ulcers are found on the lower extremity including the foot. Management includes assessment of arterial and venous blood flow to the lower extremity, wound management, and evaluation by a vascular surgeon.
All patients should be encouraged to decrease their risk factors (e.g., smoking, etc.) and to manage co-existing conditions such as diabetes.
DIABETIC NEUROPATHIC FOOT ULCERS – generally occur in diabetic patients with significant sensory neuropathy with unrecognized repetitive trauma. Management includes stopping the trauma with special shoes (off loading), assessment of arterial blood supply and wound care. Patients should be referred to the Limb Preservation Service.
MISCELLANEOUS EXTREMITY WOUND OR ULCERS - All other ulcerations assessed individually and treated according to the underlying etiology.
Neurogenic ulcers, also known as diabetic ulcers, are ulcers that occur most commonly on the bottom of the foot. People with diabetes are predisposed to peripheral neuropathy, which involves a decreased or total lack of sensation in the feet. Feet are naturally stressed from walking, and someone who has decreased sensation will not necessarily feel that they have an area of skin breakdown occurring. Coupled with this lack or absence of sensation is a decrease in circulation to the feet as well. Wounds that do not get proper blood flow are not only slower to heal but also at an increased risk for infection. A small cut, scrape, or irritated area in a diabetic can turn into an ulcer for these reasons. It is common for these types of ulcers to keep coming back in diabetics.