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Diabetic foot ulcers (DFUs) typically occur on the weight-bearing surface of the foot or the digits as a result of sensory neuropathy, bony abnormalities, and/or repeated mechanical forces (shear, friction, or direct pressure). Because patients with diabetes often present with other co-morbidities, including peripheral arterial disease (PAD), it is imperative to distinguish DFUs from other types of wounds in order to effectively diagnose and treat. A thorough vascular examination is a critical part of managing patients with DFUs, and if pedal pulses are diminished or absent, timely referral to a vascular specialist is warranted. If pedal pulses are present, DFUs can be treated with standard care as described below. However, even in the presence of palpable pedal pulses, referral to a vascular specialist should be considered for cases in which a wound fails to progress in a given period of time, or if the patient is at particularly high risk for amputation.

Clinical Guideline: Pulses are palpated with the ungloved finger directly over the dorsalis pedis and posterior tibial arteries, after removal of the patient’s socks. If pulses are diminished and confirmed with a Doppler, note that a positive Doppler sound does not equate to normal blood flow. In this case, perfusion is reduced and referral to a vascular specialist for further testing is indicated.

Patients with hyperglycemia can have impaired healing of wounds due to any etiology (e.g. surgical incisions, venous, pressure, or trauma); however, these wounds are not termed diabetic wounds. Rather, they are classified according to their etiology, for example, a non-healing pressure ulcer on a patient with diabetes. This becomes important in coding for reimbursement. The American Diabetes Association guidelines for patients with diabetes recommend that hemoglobin A1c levels be 53 mmol/mol or <7%.1 Hyperglycemia is known to impede wound healing by several mechanisms, (Table 5-1) as well as to increase the risk of infection; therefore, management of blood glucose levels is an integral component of treating any patient with diabetes who has a diabetic foot ulcer or non-healing wound.2

TABLE 5-1Impaired cellular function associated with diabetes

Diagnostic Clue: The guidelines to help determine if infection is a result of poor glucose control or if the hyperglycemia is contributing to the infection are (1) if the patient’s hemoglobin A1c is normal and blood glucose ...

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