best practice guidelines: wound management in diabetic foot ulcers

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ASSESSING DFUsAssessing DFUsPatients with a DFU need to be assessed holistically and intrinsic and extrinsicfactors consideredFor the non-specialist practitioner, the key skillrequired is knowing when and how to refer apatient with a DFU to the multidisciplinary footcareteam (MDFT; see page 19). Patients witha DFU should be assessed by the team withinone working day of presentation — or soonerin the presence of severe infection 22,36,37 . Inmany places, however, MDFTs do not exist andpractitioners instead work as individuals. Inthese situations, the patient’s prognosis oftendepends on a particular practitioner’s knowledgeand interest in the diabetic foot.Patients with a DFU need to be assessed holisticallyto identify intrinsic and extrinsic factors.This should encompass a full patient historyincluding medication, comorbidities and diabetesstatus 38 . It should also take into considerationthe history of the wound, previous DFUs oramputations and any symptoms suggestive ofneuropathy or PAD 28 .EXAMINATION OF THE ULCERA physical examination should determine: Is the wound predominantly neuropathic,ischaemic or neuroischaemic? If ischaemic, is there critical limb ischaemia? Are there any musculoskeletal deformities? What is the size/depth/location of thewound? What is the colour/status of the woundbed?— Black (necrosis)— Yellow, red, pink Is there any exposed bone? Is there any necrosis or gangrene? Is the wound infected? If so, are theresystemic signs and symptoms of infection(such as fevers, chills, rigors, metabolicinstability and confusion)? Is there any malodour? Is there local pain? Is there any exudate? What is the level ofproduction (high, moderate, low, none),colour and consistency of exudate, and is itpurulent? What is the status of the wound edge(callus, maceration, erythema, oedema,undermining)?Documenting ulcer characteristicsRecording the size, depth, appearance and locationof the DFU will help to establish a baselinefor treatment, develop a treatment plan andmonitor any response to interventions. It isimportant also to assess the area around thewound: erythema and maceration indicateadditional complications that may hinderwound healing 38 .Digitally photographing DFUs at the firstconsultation and periodically thereafterto document progress is helpful 39 . This isparticularly useful for ensuring consistencyof care among healthcare practitioners,facilitating telehealth in remote areas andillustrating improvement to the patient.TESTING FOR LOSS OF SENSATIONTwo simple and effective tests for peripheralneuropathy are commonly used: 10g (Semmes-Weinstein) monofilament Standard 128Hz tuning fork.The 10g monofilament is the most frequentlyused screening tool to determine the presenceof neuropathy in patients with diabetes 28 . Itshould be applied at various sites along theplantar aspect of the foot. Guidelines vary in thenumber of sites advocated, but the internationalconsensus is to test at three sites (see Figure5) 7 . A positive result is the inability to feel themonofilament when it is pressed against thefoot with enough force to bend it 40 .Neuropathy is also demonstrated by an inabilityto sense vibration from a standard tuning fork.Other tests are available, such as the biothesiometerand neurothesiometer, which are morecomplex handheld devices for assessing theperception of vibration.Do not test for neuropathy in areas of callusas this can mask feeling from any of theneuropathy testing devices and may give afalse-positive result.Be aware that patients with small nerve fibredamage and intact sensory nerves may have34 BEST PRACTICEBEST PRACTICEGUIDELINESGUIDELINES:FOR SKINWOUNDAND WOUNDMANAGEMENTCARE ININEPIDERMOLYSISDIABETIC FOOTBULLOSAULCERS
ASSESSING DFUsFIGURE 5: Procedure for carrying out the monofilament test (adapted from 7 )The International Working Group on the Diabetic Foot (IWGDF) recommends the following procedure for carrying out themonofilament test. The sensory examination should be carried out in a quiet and relaxed setting The patient should close their eyes so as not to see whether or where the examinerapplies the monofilament The patient should sit supine with both feet level First apply the monofilament on the patient’s hands or on the inside of the arm sothey know what to expect Apply the monofilament perpendicular to the skin surface with sufficient force tobend or buckle the monofilament Ask the patient:— Whether they feel the pressure applied (yes/no)— Where they feel the pressure (left foot/right foot) Apply the monofilament along the perimeter of (not on) the ulcer site Do not allow the monofilament to slide across the skin or make repetitive contact atthe test site The total duration of the approach (skin contact and removal of the monofilament)should be around 2 seconds Apply the monofilament to each site three times, including at least one additional‘mock’ application in which no filament is applied Encourage the patient during testing by giving positive feedback— Protective sensation is present at each site if the patient correctly answers twoout of three applications— Protective sensation is absent with two out of three incorrect answersNote: The monofilament should not be used on more than 10 patients without arecovery period of 24 hoursUsing a monofilament to test for neuropathya painful neuropathy. They may describesharp, stabbing, burning, shooting or electricshock type pain, which may be worse at nightand can disrupt sleep 41 . The absence of coldwarmdiscrimination may help to identifypatients with small nerve fibre damage.TESTING FOR VASCULAR STATUSPalpation of peripheral pulses should be aroutine component of the physical examinationand include assessment of the femoral,popliteal and pedal (dorsalis pedis andposterior tibial) pulses. Assessment of pulsesis a learned skill and has a high degree ofinter-observer variability, with high falsepositiveand false-negative rates. The dorsalispedis pulse is reported to be absent in 8.1%of healthy individuals, and the posterior tibialpulse is absent in 2.0%. Nevertheless, theabsence of both pedal pulses, when assessedby an experienced clinician, strongly suggeststhe presence of pedal vascular disease 42 . Ifthere is any doubt regarding diagnosis of PAD,it is important to refer to a specialist for a fullvascular assessment.Where available, Doppler ultrasound, anklebrachialpressure index (ABPI) and Dopplerwaveform may be used as adjuncts tothe clinical findings when carried out by acompetent practitioner. Toe pressures, andin some instances, transcutaneous oxygenmeasurement (where equipment is available),may be useful for measuring localtissue perfusion.An ischaemic foot may appear pink and relativelywarm even with impaired perfusion dueto arteriovenous shunting. Delayed discolouration(rubor) or venous refilling greater thanfive seconds on dependency may indicatepoor arterial perfusion 43 .Other signs suggestive of ischaemia include 40 : Claudication: pain in the leg muscles andCOMMON TERMS EXPLAINEDCritical limb ischaemia: this isa chronic manifestation of PADwhere the arteries of the lowerextremities are severely blocked.This results in ischaemic painin the feet or toes even at rest.Complications of poor circulationinclude skin ulcers or gangrene.If left untreated it will result inamputation of the affected limb.Acute limb ischaemia: thisoccurs when there is a suddenlack of blood flow to a limb andis due to either an embolism orthrombosis. Without surgicalrevascularisation, completeacute ischaemia leads to extensivetissue necrosis within sixhours.BEST PRACTICE GUIDELINES: WOUND MANAGEMENT IN DIABETIC FOOT ULCERS 5
Page 1 and 2: INTERNATIONAL BEST PRACTICEBEST PRA
Page 3 and 4: INTRODUCTIONIntroductionDFUs are co
Page 5: AETIOLOGY OFDFUsAetiology of DFUsTh
Page 9 and 10: ASSESSING DFUsBOX 1: Signs of sprea
Page 11 and 12: DFU WOUNDMANAGEMENTDFU wound manage
Page 13 and 14: DFU WOUNDMANAGEMENTHydrosurgical de
Page 15 and 16: DFU WOUNDMANAGEMENTantimicrobial ag
Page 17 and 18: DFU WOUNDMANAGEMENTTABLE 6: Wound m
Page 19 and 20: DFU WOUNDMANAGEMENTexclusion of inf
Page 21 and 22: Integrated care approachINTEGRATEDC
Page 23 and 24: REFERENCES1. National Institute for
Page 25 and 26: REFERENCES94. International Consens

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