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Tools Wisconsin Diabetes Mellitus Essential Care Guidelines • 2012 57 DIABETIC FOOT ULCERATION • Duration of ulcer • Previous ulceration • Pain/sensation • Vascular history Significant History General Foot Exam • Vascular • Neurologic • Structural deformity • Dermatologic Vascular • Palpate pedal pulses • Noninvasive vascular studies Diagnostic Imaging • Plain radiographs • Imaging studies – CT – MRI – Bone scan – Ultrasound Ulcer Examination • Classiﬁcation • Size, depth • Location • Deformity • Extent of necrosis • Probe to bone * Additional diagnostic procedures as indicated Peripheral Vascular Consultation Presence of GANGRENE PAD Infection • Wound Infection • Osteomyelitis Proceed to Pathway #4 WOUND CARE • Debridement – Sharp – Enzymatic – Hydrosurgery – Ultrasound • Moisture balance/dressings • Advanced wound management – Growth factors – Bioengineered tissues – HBO – Negative pressure (NPWT) Initial Ulcer Treatment OFF-LOADING • Bed rest • Surgical shoe/healing sandal • Bracing • Total contact casts • Wheelchair • Crutches Proceed to Pathway #2 Tx PAD RE-EVALUATE If ulcer recurs, treat appropriately: • Re-evaluate vascularity • Rule out osteomyelitis Long-term Management of Healed Ulcer • Patient education • Frequent re-evaluation • Protective shoes, etc., see below: • Bracing • Extra depth shoes • Custom moulded shoes • Multiple density insoles • Orthoses WOUND HEALED WOUND FAILS TO HEAL • Re-evaluate vascularity • Re-evaluate for infection/ osteomyelitis • Biopsy to assess for malignancy Surgical Management • Debridement – Soft tissue – Bone • Exostectomy • Correct deformity • Plastic surgery OSTEOMYELITIS ULCERATION +/- Deformity Refer to Pathway #1 © 2006 by the American College of Foot and Ankle Surgeons. All rights reserved. The full guideline, including details regarding this pathway, is available at: acfas.org/cpg. Pathway # 2 can be found at: http://www.acfas.org/uploadedFiles/Healthcare_Community/Education_and_Publications/Clinical_Practice_Guidelines/pway2--pad.pdf. Pathway # 4 can be found at: http://www.acfas.org/uploadedFiles/Healthcare_Community/Education_and_Publications/Clinical_Practice_Guidelines/pway4--infection.pdf.

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ToolsWisconsin Diabetes Mellitus Essential Care Guidelines • 2012

DIABETIC FOOT ULCERATION

• Duration of ulcer• Previous ulceration• Pain/sensation• Vascular history

Significant History

General Foot Exam• Vascular• Neurologic• Structural deformity• Dermatologic

Vascular• Palpate pedal pulses• Noninvasive vascular

studies

Diagnostic Imaging• Plain radiographs• Imaging studies – CT – MRI – Bone scan – Ultrasound

Ulcer Examination• Classifi cation• Size, depth• Location• Deformity• Extent of necrosis• Probe to bone

* Additional diagnostic procedures as indicated

Peripheral VascularConsultation

Presence of GANGRENE

PAD Infection

• Wound Infection• Osteomyelitis

Proceed to Pathway #4

WOUND CARE• Debridement – Sharp – Enzymatic – Hydrosurgery – Ultrasound• Moisture balance/dressings• Advanced wound

management – Growth factors – Bioengineered tissues – HBO – Negative pressure

(NPWT)

Initial Ulcer Treatment

OFF-LOADING• Bed rest• Surgical shoe/healing sandal• Bracing• Total contact casts• Wheelchair• Crutches

Proceed to Pathway #2

Tx PAD

RE-E

VALU

ATE

If ulcer recurs, treat appropriately:• Re-evaluate vascularity• Rule out osteomyelitis

Long-term Managementof Healed Ulcer• Patient education• Frequent re-evaluation• Protective shoes, etc.,

see below:

• Bracing• Extra depth shoes• Custom moulded shoes• Multiple density insoles• Orthoses

WOUND HEALED

WOUND FAILS TO HEAL

• Re-evaluate vascularity

• Re-evaluate for infection/osteomyelitis

• Biopsy to assess for malignancy

Surgical Management• Debridement – Soft tissue – Bone• Exostectomy• Correct deformity• Plastic surgery

OST

EOM

YELI

TIS

ULCERATION+/- Deformity

Refe

r to

Path

way

© 2006 by the American College of Foot and Ankle Surgeons. All rights reserved. The full guideline, including details regarding this pathway, is available at: acfas.org/cpg.Pathway # 2 can be found at: http://www.acfas.org/uploadedFiles/Healthcare_Community/Education_and_Publications/Clinical_Practice_Guidelines/pway2--pad.pdf.Pathway # 4 can be found at: http://www.acfas.org/uploadedFiles/Healthcare_Community/Education_and_Publications/Clinical_Practice_Guidelines/pway4--infection.pdf.

http://www.acfas.org/uploadedFiles/Healthcare_Community/Education_and_Publications/Clinical_Practice_Guidelines/pway2--pad.pdf

http://www.acfas.org/uploadedFiles/Healthcare_Community/Education_and_Publications/Clinical_Practice_Guidelines/pway4--infection.pdf

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