summary Diabetic Foot Ulcers are very common lower extremity wounds that occur in diabetics with peripheral neuropathy and are responsible for 85% of lower extremity amputations. Diagnosis is made clinically with presence of a plantar foot ulcer which may probe to bone. MRI studies are useful to assess for presence and extent of osteomyelitis. Treatment depends on ulcer size, ulcer thickness, ulcer location and presence of concomitant infection. Epidemiology Incidence approximately 12% of diabetics have foot ulcers most common medical complication causing diabetics to get medical treatment foot ulcers are responsible for ~85% of lower extremity amputations Risk factors factors associated with decreased healing potential uncontrolled hyperglycemia (Hb A1C > 8.0) inability to offload the affected area poor circulation infection poor nutrition factors associated with increased healing potential serum albumin > 3.0 g/dL total lymphocyte count > 1,500/mm3 Etiology Pathophysiology neuropathy has largest effect on diabetic foot pathology sensory dysfunction leads to lack of protective sensation and is primary risk factor for ulcer development autonomic dysfunction leads to drying of skin due to lack of normal glandular function net effect is increased mechanical and axial stress on skin that is more prone to injury due to drying angiopathy lesser effect than neuropathy >60% of diabetic ulcers have decreased blood flow due to peripheral vascular disease Associated condition infection / osteomyelitis high rates of associated osteomyelitis if bone is able to be probed, or is exposed at the base of the ulcer 67% of ulcers that probe to bone have osteomyelitis organisms usually polymicrobial gram-positive most common pathogens are aerobic gram positive cocci (s. aureus) gram-negative increased gram-negative organisms are found in chronic wounds and wounds recently treated with antibiotics anaerobes obligate anaerobic pathogens with ischemia or gangrene deep cultures and bacterial biopsies help guide management Classification Wagner Classification and Treatment Description Treatment Grade 0 Skin intact but bony deformities lead to "foot at risk" Shoe modifications with serial exams Grade 1 Superficial ulcer Office debridement and contact casting Grade 2 Deeper, full thickness extension Operative formal debridement and contact casting Grade 3 Deep abscess formation or osteomyelitis Operative formal debridement and contact casting Grade 4 Partial Gangrene of forefoot Local vs. larger amputation Grade 5 Extensive Gangrene Amputation Brodsky Depth-Ischemia Classification and Treatment Depth Classification Definition Treatment 0 At risk foot, no ulceration Patient education, accommodative footwear, regular clinical examination 1 Superficial ulceration, not infected Off-loading with total contact cast, walking brace or special footwear 2 Deep ulceration, exposing tendons or joints Surgical debridement, wound care, off-loading, culture-specific antibiotics 3 Extensive ulceration or abscess Debridement or partial amputation, off-loading, culture-specific antibiotics Ischemia A Not ischemic B Ischemia without gangrene Non-invasive vascular testing and vascular reconstruction with angioplasty/bypass C Partial forefoot gangrene Vascular reconstruction and partial foot amputation D Complete gangrene Complete vascular evaluation and major extremity amputation Presentation Symptoms often painless Physical exam depth of ulcer probe for bone presence of infection look for cellulitis, pus check for gangrene assess Achilles tendon tightness Silverskiöld test improved ankle dorsiflexion with knee flexed = gastrocnemius tightness equivalent ankle dorsiflexion with knee flexion and extension = Achilles tightness circulation assess dorsalis pedis and posterior tibialis pulses Studies Transcutaneous oxygen pressures (TcpO2) considered Gold Standard to assess wound healing potential > 30 mm Hg (or 40mmHg depending on review source cited) is a good sign of healing potential ABI's and ischemic index calcification in the arteries can result in inaccurate doppler flow readings calcifications falsely elevate the ABI's due to decreased compliance of the calcified vessels index of > 0.45 and toe pressure >45mm Hg are needed to heal amputation and >60mm Hg to heal an ulcer Imaging Radiographs recommended views AP, lateral, and oblique of foot and ankle MRI best for differentiating abscess from soft tissue swelling difficult to differentiate infection from Charcot arthropathy on MRI Bone scan views obtain with technetium Tc99m, gallium (Ga)67, or indium (In) 111 useful to differentiate between soft tissue infection osteomyelitis Charcot arthropathy Treatment General factors important in deciding a treatment plan include angiopathic vs. neuropathic deep vs. superficial +/- osteomyelitis, antibiotics based on bone biopsy culture sensitivities +/- pyarthrosis Nonoperative shoe modification indications prevention when signs of potential ulcers are present includes deep or wide shoes, custom insoles, rocker bottom soles, etc. of the available shoe only modifications, rocker sole shoes best reduce the plantar pressure on the forefoot medicare will cover modifications and custom shoes/insoles yearly wound care indications first line of treatment goals of wound care and dressings provide moist environment absorb exudate act as a barrier off-load pressure at ulcer total contact casting (TCC) indications gold standard for mechanical relief plantar ulcerations contraindications absolute infection relative marginal arterial supply to affected area patients unable to comply with cast care patients unable to tolerate a cast (cast claustrophobia) outcomes if ulcer recurs, it is typically 3-4 weeks after cast removal Operative surgical debridement, antibiotics, contact casting +/- gastroc recession/TAL indications grade 3 or greater ulcers should undergo I&D with antibiotic treatment before casting outcomes high rates of associated osteomyelitis if bone is able to be probed, or is exposed at the base of the ulcer ostectomy +/- TAL indications bony prominence causing internal pressure technique TAL indicated if tight Achilles several studies have shown TAL to be effective to help heal and prevent recurrence of plantar forefoot ulcers partial calcanectomy +/- TAL indications large heel ulcers with associated calcaneal osteomyelitis outcomes preserves limb length and decreases morbidity compared to higher level amputations Syme amputation indications forefoot gangrene and a palpable posterior tibial artery pulse Keller resection arthroplasty indications IPJ plantar neuropathic ulcer with hypomobile/stiff MTPJ that has failed total contact casting Techniques Total Contact Casting often necessary for up to 4 months TCC followed by Charcot restraint walker then custom shoe pneumatic walking brace alternative to TCC, same principal allows better wound surveillance significant deformity and/or extremely large girth often requires custom pneumatic walkers patient compliance with offloading can be an issue because the pneumatic walker is removable Prognosis Diabetic foot ulceration is considered the most likely predictor of eventual lower extremity amputation in patients with diabetes mellitus
Technique Guide Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. Percutaneous Achilles Tendon Lengthening Orthobullets Team Pediatrics - Cavovarus Foot in Pediatrics & Adults Technique Guide Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. Removal of Plantar-Hindfoot-Midfoot Bony Mass Orthobullets Team Foot & Ankle - Diabetic Foot Ulcers Technique Guide Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. Midfoot Amputation Orthobullets Team Trauma - Amputations Technique Guide Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. Below Knee Amputation Orthobullets Team Trauma - Amputations
QUESTIONS 1 of 33 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ15.232) A 50-year-old-man with a history of uncontrolled diabetes mellitus has a plantar foot ulcer that has failed 2 months of contact casting. Physical exam is significant for a persistent deep, full-thickness ulcer but with no gross purulence. The foot is erythematous, and this persists despite adequate elevation. What is the next best step? QID: 5917 Type & Select Correct Answer 1 Continuation of contact casting 8% (127/1608) 2 Broad-spectrum IV antibiotics for 6 weeks 6% (91/1608) 3 In-office wound culture with directed antibiotic therapy 5% (88/1608) 4 Intra-operative debridement and irrigation with culture 79% (1274/1608) 5 Skin grafting 1% (18/1608) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ12.189) A 66-year-old male with a known history of uncontrolled Type 2 diabetes presents for follow up of a forefoot ulcer that is seen in Figure A. All of the following are strong prognostic indicators of osteomyelitis EXCEPT: QID: 4549 FIGURES: A Type & Select Correct Answer 1 Exposed bone at ulcer site 3% (107/4144) 2 Periarticular erosions at 1st MTP joint 11% (474/4144) 3 Increased signal within metatarsal diaphysis on T2 weighted MRI 5% (189/4144) 4 Increased signal within indium labeled WBC scan 3% (130/4144) 5 Positive wound culture 77% (3207/4144) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ11.151) A 55-year-old female with longstanding type I diabetes presents for evaluation of her left foot, which is shown in Figure A. On exam, the soft tissue infection extends to the metatarsals plantarly, and there is a palpable posterior tibial artery pulse. She is otherwise medically stable, and without sepsis. Which of the following treatment options will most likely result in definitive management of her forefoot gangrene and allow the highest level of functional activity after surgery? QID: 3574 FIGURES: A Type & Select Correct Answer 1 Transmetatarsal amputation 22% (671/2999) 2 Below the knee amputation 8% (225/2999) 3 Syme amputation 68% (2054/2999) 4 Above the knee amputation 0% (8/2999) 5 Extensive soft-tissue debridement, local wound care, and antibiotic therapy 1% (30/2999) L 3 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic (OBQ10.150) A 65-year-old diabetic male presents with the foot ulcer shown in Figure A. There is no exposed bone, and no signs of infection. Pulses are palpable. What additional information should be obtained next to help guide this patient's treatment? QID: 3238 FIGURES: A Type & Select Correct Answer 1 MRI scan with contrast 5% (175/3373) 2 Ankle-brachial index 11% (381/3373) 3 Results of Silfverskiold test 58% (1961/3373) 4 Transcutaneous oxygen measurements of the toes 16% (524/3373) 5 Hemoglobin A1C level 9% (319/3373) L 3 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic (OBQ10.81) A 44-year-old male with long standing insulin dependent diabetes complains of a non-healing plantar foot ulcer. The ulcer is shown in Figure A. The second metatarsal head can be probed at the base of the wound, and he lacks plantar sensation. Laboratory work-up for infection is negative. Which of the following is the best initial treatment? QID: 3169 FIGURES: A Type & Select Correct Answer 1 Ray resection and primary wound closure 3% (84/2707) 2 Oral antibiotics and local wound care 2% (45/2707) 3 Local wound care and non-weight bearing in a removable boot 24% (646/2707) 4 Surgical debridement, dressing changes, and IV antibiotics 54% (1462/2707) 5 Transmetatarsal amputation 17% (463/2707) L 4 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (OBQ10.261) A 44-year-old man with diabetes mellitus has a non-healing Wagner grade 1 ulcer shown in Figure A for the past 8 months. Conservative management with total contact casting has not resolved the ulcer. Physical examination reveals loss of protective sensation by Semmes-Weinstein testing, no signs of infection, positive Silfverskiold test indicating gastrocnemius contracture, and palpable pedal pulses. What is the next most appropriate step in management? QID: 3358 FIGURES: A Type & Select Correct Answer 1 Integra artificial dermis placement followed by split thickness skin grafting 2% (75/3476) 2 Continued total contact casting 3% (95/3476) 3 Split thickness skin grafting to ulcer 1% (37/3476) 4 Strayer procedure (gastrocnemius lengthening) 89% (3105/3476) 5 Weil metatarsal decompression osteotomy 4% (144/3476) L 1 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (OBQ09.104) A 65-year-old patient with poorly controlled diabetes develops 2nd metatarsal head osteomyelitis deep to a superficial ulcer. Which of the following treatment modalities would have the highest chance of success? QID: 2917 Type & Select Correct Answer 1 IV Vancomycin 2% (49/3202) 2 Oral Levofloxacin 0% (11/3202) 3 IV antibiotics based on ulcer swab culture sensitivity 2% (61/3202) 4 IV antibiotics based on percutaneous bone biopsy culture sensitivity 94% (3011/3202) 5 Elevation and non-weight bearing 2% (56/3202) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ09.130) A 57-year-old man taking metformin for diabetes and gabapentin for peripheral neuropathy has a superficial plantar midfoot ulcer with a clean, noninfected appearance. Total contact casting is implemented for mechanical relief. Which of the following radiographs most likely corresponds to the clinical situation described? QID: 2943 FIGURES: A B C D E Type & Select Correct Answer 1 Figure A 0% (11/2393) 2 Figure B 1% (33/2393) 3 Figure C 72% (1734/2393) 4 Figure D 8% (187/2393) 5 Figure E 17% (415/2393) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic (OBQ09.271) You are caring for a 72-year-old male with diabetes and peripheral neuropathy with a non-healing forefoot ulcer as shown in Figure A. To reduce the plantar pressure on his forefoot, which of the following shoe modifications would you suggest? QID: 3084 FIGURES: A Type & Select Correct Answer 1 Polyethylene foam insole 9% (225/2644) 2 Open toe sandals 0% (6/2644) 3 Rocker sole shoes 64% (1686/2644) 4 Custom indepth shoes 26% (675/2644) 5 Hard postoperative shoe 2% (44/2644) L 3 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ08.253) A 55-year-old man with diabetes underwent successful casting for a neuropathic plantar foot ulcer. Within what time period after discontinuation of the cast is the ulcer most likely to recur? QID: 639 Type & Select Correct Answer 1 2 days 0% (12/2526) 2 1 week 5% (123/2526) 3 1 month 56% (1404/2526) 4 6 months 35% (875/2526) 5 1 year 4% (99/2526) L 4 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic (OBQ07.125) Which of the following variables is not predictive of poor healing of diabetic foot ulcers? QID: 786 Type & Select Correct Answer 1 Transcutaneous oxygen pressure < 20 mmHg 3% (60/2376) 2 Systolic blood pressure > 140 mmHg 87% (2076/2376) 3 Ankle-brachial index < 0.45 2% (43/2376) 4 Albumin < 3.0 g/dL 1% (28/2376) 5 Total lymphocyte count < 1,500/mm3 7% (159/2376) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic (OBQ07.90) A 45-year-old diabetic male has a Wagner type 3 heel ulcer shown in Figure A that measures 4x2cm and is recalcitrant to debridements and total contact casting for 4 months. The patient has palpable pulses, active drainage at the ulcer, and does not have protective sensation with a 5.07 Semmes-Weinstein filament. Radiograph and MRI (sagittal and axial) images are shown in Figures B-D respectively. In addition to bone culture biopsy, debridement and antibiotic therapy, what surgical intervention is most appropriate? QID: 751 FIGURES: A B C D Type & Select Correct Answer 1 Ankle disarticulation 4% (111/2857) 2 Soft tissue fasciocutaneous flap coverage 7% (204/2857) 3 Partial calcanectomy 74% (2128/2857) 4 Below knee amputation 10% (275/2857) 5 Soft tissue free flap coverage 4% (121/2857) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic (OBQ06.224) Which of the following is least likely to predict future amputation in diabetic patients? QID: 235 Type & Select Correct Answer 1 Diabetic foot ulceration 3% (48/1465) 2 Loss of sensation with 5.07 Semmes-Weinstein monofillament testing 7% (100/1465) 3 Infection 3% (39/1465) 4 Hemoglobin A1c level of 10.7 5% (67/1465) 5 Ankle-brachial index of 1.07 82% (1203/1465) L 1 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic (OBQ06.117) Which of the following is not financially covered during one calendar year for Medicare patients under the United States Therapeutic Shoe Bill? QID: 303 Type & Select Correct Answer 1 Three pair of inserts for extra-depth shoes 23% (314/1343) 2 Shoe wedges 6% (81/1343) 3 Inserts for missing toes 7% (99/1343) 4 Two pairs of custom-molded shoes 55% (740/1343) 5 Velcro closure shoe modification 7% (96/1343) L 4 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (OBQ06.158) A 62-year-old diabetic female presents with a Wagner grade 1 foot ulcer. Upon examination of the foot, no dorsalis pedis pulse is palpable. Each of the following noninvasive vascular tests indicate a good prognosis for ulcer healing EXCEPT: QID: 344 Type & Select Correct Answer 1 Triphasic waveforms 2% (26/1691) 2 Ankle-brachial indices (ABI) of 0.72 28% (475/1691) 3 Absolute toe pressure of 45 mm Hg 3% (53/1691) 4 Transcutaneous oxygen measurements (pO2) of 15mm Hg 64% (1075/1691) 5 Presence of hair on the toes 3% (51/1691) L 2 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (OBQ06.54) Which of the following patients with type 2 diabetes mellitus is most likely to develop a foot ulcer? QID: 165 Type & Select Correct Answer 1 54-year-old female unable to feel the presence of a 5.07 Semmes-Weinstein monofilament on the plantar aspect of the foot 77% (986/1273) 2 63-year-old male with transcutaneous oxygen pressures (TcpO2) of 30 mm Hg 4% (56/1273) 3 51-year-old male with ratio of ankle to brachial pressures of < 0.6 14% (179/1273) 4 71-year-old male with serum albumin of 3.1 g/dL 1% (9/1273) 5 60-year-old with autonomic dysfunction leads to drying of skin due to lack of normal glandular function 3% (32/1273) L 2 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic (OBQ05.20) A 34-year-old patient is noted to have a lack of ankle dorsiflexion by 5 degrees with knee extension as seen in Figure A. However, the ankle dorsiflexion improves to 20 degrees with knee flexion as seen in Figure B. Which of the following diagnoses would benefit MOST from a gastrocnemius recession (Strayer procedure)? QID: 57 FIGURES: A B Type & Select Correct Answer 1 Chronic peroneal tendonitis 10% (315/3151) 2 Freiberg's infraction 3% (105/3151) 3 Chronic retrocalcaneal bursitis 7% (208/3151) 4 Chronic calcaneal osteomyelitis 1% (31/3151) 5 Chronic plantar forefoot ulcer 78% (2470/3151) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic (OBQ04.84) A 37-year-old man with type-1 diabetes mellitus reports a 3-month history of a plantar foot ulcer shown in Figure A. His pulses are palpable and sensation to a 5.07 Semmes-Weinstein monofilament is absent on the entire plantar surface of the foot. There is no erythema or drainage and there is no bone encountered during probing of the ulcer. There is no fever and the white blood cell count is normal. The C-reactive protein and erythrocyte sedimentation rate are normal. What is the most appropriate next step in treatment? QID: 1189 FIGURES: A Type & Select Correct Answer 1 Total contact casting and empiric IV antibiotics 3% (73/2167) 2 Surgical debridement, dressing changes, and empiric IV antibiotics 3% (73/2167) 3 Charcot restraint orthotic walker (CROW) 5% (113/2167) 4 Surgical debridement, dressing changes, biopsy, and culture specific IV antibiotics 8% (180/2167) 5 Total contact casting 79% (1714/2167) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic
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