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Hi,

Have been treating diabetic ulcer on apex of 3rd digit for 8 weeks. (History of ulceration and cellulitis) Pt is 78 yo type 1 diabetes with peripheral neuropathy but reasonable blood flow. This is ulcer is secondary to infection caused by incorrect dressing given by carer and also being on area of pressure, so I have tried several offloading techniques. The digit has been swollen but not inflamed, so I put the swelling down to fluid and general irritation of the area due to pressure. Temperature was normal. Minimal discharge at beginning - none of late. Last visit wound looked really good and I expected to be able to discharge this visit.

Today the patient arrived with the wound bleeding, the digit inflamed and swollen - (but the swelling was very hard on palpation and didn't seem like normal fluid -more like lymphodema type swelling. It was also exaggerated in one area -plantar from webspace to proximal IPJ ) and ulcer back to stage one.

Sent her off to Doctor to arrange anti-biotics and xray.

My biggest concern is the change in the size of the digit. Never seen this before -has anyone else?? Any ideas.

SRD

 

The ulceration is due to abnormal tissue stress and peripheral neuropathy - not infection. It came later as a result of the hole in the foot.

The oedema is due to the presence of cellulitis +/- osteomyelitis.

The treatment will be to treat the infection with oral and/or IV antibiotics initially and then heal the ulceration next.

The most effective long term treatment for apical neuropathic ulcerations with intact arterial status that I have seen/used is a (literally 30 second - with or without anaesthesia as required) percutaneus flexor tenotomy + standard wound care. Refer to your local podiatric or orthopaedic surgeon once the infection is under control - otherwise you will be back in this same situation again within no time...

LL