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Diabetic Foot Ulcer: Full History Taking and Physical Examination

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OVERVIEW

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PART 1 - HISTORY TAKING

A. Presenting Complaint

• Nature of the wound: when first noticed, how it started (blister, callus, crack, trauma)
• Duration of the ulcer
• Rate of change: getting larger, smaller, or static
• Pain or painlessness (painless = suggests neuropathy; painful = suggests ischemia or infection)
• Any discharge: character (serous, purulent, bloody, foul-smelling)

Because of impaired sensation, patients may deny any history of trauma or pain before the development of a foot ulcer. - Campbell's Operative Orthopaedics 15e

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B. Diabetes History

• Type of diabetes (Type 1 or Type 2), duration of diagnosis
• Current medications: insulin (type, dose, regimen), oral hypoglycaemics
• Glycaemic control: last HbA1c, home blood glucose monitoring, pattern of readings
• Frequency of hypoglycaemic episodes
• Compliance with medications and diet
• Monitoring: frequency of seeing diabetic nurse/dietitian/podiatrist

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C. Foot-Specific History

• Previous ulcers: number, sites, healing time, treatment required
• Previous amputations: level, side, reason, year
• History of Charcot neuroarthropathy (Charcot joint): sudden swelling, warmth, redness of foot or ankle in absence of infection
• Footwear: type of shoes worn, whether custom therapeutic footwear has been prescribed, ability to feel foreign bodies or seams inside the shoe
• Foot care routine: ability to inspect own feet daily, ability to reach feet (limited by obesity, visual impairment), hygiene habits
• Prior foot surgeries or procedures

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D. Neuropathy Symptoms

• Sensory neuropathy: numbness, tingling, burning, "walking on cotton", loss of feeling in the feet
• Motor neuropathy: weakness, difficulty walking, change in foot shape
• Autonomic neuropathy: decreased sweating (anhidrosis), dry cracked skin, postural dizziness (orthostatic hypotension)
• Pain characteristics: burning, stabbing, electric, or absence of pain (protective sensation loss)

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E. Vascular / Ischemia History

• Claudication: calf or thigh pain on walking (intermittent claudication) - note claudication distance
• Rest pain: pain in toes/forefoot at rest, worse at night, relieved by hanging the leg over the bed edge
• Critical limb ischemia: rest pain, non-healing wounds, or gangrene
• Prior vascular interventions: angioplasty, bypass surgery, stenting
• Smoking history (pack-years) - major risk factor for peripheral arterial disease (PAD)
• History of stroke or myocardial infarction (markers of systemic atherosclerosis)

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F. Infection History

• Constitutional symptoms: fever, chills, rigors, malaise
• Local symptoms: increasing redness, warmth, swelling around the wound
• Discharge: purulent or foul-smelling
• Crepitus felt around wound (gas-forming organisms)
• Recent antibiotic treatment (type, duration, response)
• Hospitalisation for foot infection in the past
• Any probe-to-bone sensation during dressing changes

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G. Systemic Diabetic Complications

• Retinopathy: visual impairment or blindness - impacts ability to inspect own feet; increases falls risk
• Nephropathy: CKD stage, dialysis, transplant history - impacts wound healing, drug dosing
• Cardiovascular disease: IHD, heart failure, hypertension, dyslipidaemia
• Cerebrovascular disease: stroke, TIA

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H. Social and Functional History

• Living situation: alone or with carers, home support
• Mobility and weight-bearing status prior to ulceration
• Occupation (if still working)
• Smoking, alcohol use
• Access to healthcare, follow-up, transport
• Body weight and BMI

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I. Drug and Allergy History

• Full medication list including anticoagulants, immunosuppressants, steroids (all impair healing)
• Allergy history (important before antibiotic prescribing)
• Previous antibiotic sensitivities or resistance patterns

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J. Family History

• Family history of diabetes, PAD, or lower extremity amputation

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PART 2 - PHYSICAL EXAMINATION

General Inspection

• Overall appearance: unwell, febrile, confused (sepsis screening)
• Body habitus: obesity
• Mobility: weight-bearing or non-weight-bearing
• Diabetic facial/body features

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Vital Signs

• Temperature (fever suggests infection)
• Heart rate (tachycardia in sepsis)
• Blood pressure (hypertension common)
• Respiratory rate and oxygen saturation
• Blood glucose (at time of presentation)

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Shoe Inspection (Box 91.1 - Campbell's Orthopaedics)

"Inspect the patient's shoes." - Campbell's Operative Orthopaedics 15e

• Undersized shoes increase pressure over bony prominences, leading to ulceration and infection
• Toe box must be adequate to accommodate forefoot deformities
• Abnormal wear pattern indicates structural or dynamic foot deformity
• Presence of prominent seams or foreign bodies inside the shoe that the patient cannot feel = indicates neuropathy

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Lower Limb Inspection

• Deformities: claw toes, hammer toes, hallux valgus, flat foot (pes planus), pes cavus, Charcot foot (rocker-bottom deformity)
  • Weak intrinsic muscles overpowered by extrinsic muscles lead to claw/hammer toes and distal migration of the fat pad - Campbell's
• Muscle wasting: atrophy of the extensor digitorum brevis = motor neuropathy
• Calluses and corns: indicate sites of elevated pressure; precursors to ulceration
• Arch and hindfoot alignment (with patient weight-bearing): abnormalities alter plantar pressure distribution

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Skin Assessment

• Distinguish Charcot from infection: elevate the extremity - Charcot erythema/warmth usually subsides with elevation; infection does not.

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Ulcer Assessment

1. Site: plantar surface (most common in neuropathic), toes (pressure/ischemia), heel (pressure), inter-digital (maceration/infection), malleolus
2. Size: measure in two dimensions (longest x widest) to obtain cross-sectional area; depth should be recorded
   • Ulcers <1 cm² have 96% healing rate without amputation; ulcers >3 cm² have only 72% - Campbell's
3. Shape and margins: punched-out (ischemic), irregular, undermined edges
4. Depth: superficial (skin only), partial thickness, full thickness, exposed tendon/bone/joint
5. Wound base: granulation tissue (healthy, pink/red), fibrinous slough (yellow), necrotic tissue (black/eschar)
6. Surrounding tissue: callus, maceration, cellulitis, lymphangitis
7. Discharge: serous, serosanguineous, purulent, foul-smelling
8. Probe-to-bone test: use a sterile cotton swab to probe the wound depth and extent
   • Probing to bone has 57% positive predictive value for osteomyelitis and 96% negative predictive value - Campbell's Orthopaedics 15e

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Vascular Assessment

"Physical examination of the foot for ischemia begins with the assessment of pulses. However, this can be exceedingly tricky in the diabetic patient population..." - Current Surgical Therapy 14e

• Femoral artery
• Popliteal artery
• Posterior tibial artery (behind medial malleolus)
• Dorsalis pedis artery (dorsum of foot, lateral to extensor hallucis longus)
• Grade: normal, diminished, absent
• Note: diabetic medial calcinosis can cause falsely elevated or non-compressible vessels - absent pulses on palpation do not always mean absent flow

• Non-invasive screening tool using Doppler and blood pressure cuff
• Normal: 1.0-1.3
• Mild PAD: 0.7-0.9
• Moderate PAD: 0.4-0.7
• Severe/critical ischemia: <0.4
• ABI >1.3 suggests medial calcinosis (non-compressible vessels) - measure toe-brachial index (TBI) instead
• ABI is a useful noninvasive screening tool that predicts wound healing potential - Campbell's

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Neurological Assessment

1. Semmes-Weinstein 10-g monofilament (most important):
   • Test 10 standard plantar sites (hallux, 1st/3rd/5th metatarsal heads, plantar arch, heel, dorsum)
   • Inability to feel 10 g of pressure = loss of protective sensation (LOPS)
   • "The threshold of importance is the inability to feel a Semmes-Weinstein 5.07 monofilament" - Campbell's
   • Inability to feel 10 g of pressure is one of the most predictive risk factors for foot morbidity
2. Additional sensory modalities (at least one required alongside monofilament):
   • Pinprick sensation (pain)
   • Temperature discrimination (warm/cold test tubes)
   • Vibration sense: 128 Hz tuning fork at great toe and medial malleolus
   • Proprioception: joint position sense at hallux
3. Ankle and knee reflexes: absent ankle jerk is characteristic of peripheral neuropathy

• Power of toe extension and flexion, ankle dorsiflexion and plantarflexion
• Assessment for foot drop

• Sweating: dry feet, cracked heel skin
• Postural blood pressure drop

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Range of Motion Assessment

• Record ankle dorsiflexion with knee flexed and extended
• Gastrocnemius contracture: dorsiflexion less with knee extended than flexed (gastrocnemius origin is proximal to knee)
• Achilles tendon contracture: equal decrease in both positions
• Equinus deformity increases forefoot plantar pressure and contributes directly to plantar ulceration

• Fixed hammer or claw toe deformities
• Limited joint mobility (LJM) syndrome in diabetes: joint stiffness due to glycosylation of collagen

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Systemic Examination

• Cardiovascular: heart sounds, signs of cardiac failure (elevated JVP, ankle oedema), peripheral oedema
• Respiratory: examine if suspecting systemic sepsis
• Eyes: refer history of retinopathy - not always formally examined in clinic
• Renal: oedema may reflect CKD-related fluid retention (impacts healing)
• Lymph nodes: inguinal lymphadenopathy in lower limb infection

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PART 3 - ULCER CLASSIFICATION SYSTEMS

Wagner-Meggitt Classification (most widely used)

University of Texas (UT) Classification

• A: clean wound
• B: infected wound
• C: ischemic wound
• D: infected and ischemic wound

"Ulcers that are infected and ischemic are 90 times more likely to be treated with amputation than ulcers without infection or ischemia. The presence of an infected ulcer portends a 40% to 55% chance of some form of amputation." - Campbell's Operative Orthopaedics 15e

WIfI Classification (Society for Vascular Surgery)

• Wound grade 0-3
• Ischemia grade 0-3
• foot Infection grade 0-3
• 64 possible permutations; predicts amputation risk at 1 year and benefit of revascularisation - Current Surgical Therapy 14e

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PART 4 - INVESTIGATIONS TO PLAN AFTER HISTORY AND EXAM

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KEY CLINICAL PEARLS

• Painlessness of an ulcer does not mean it is benign - it signals dangerous loss of protective sensation
• Neuropathic ulcers are typically plantar, punched-out, surrounded by callus, with a warm foot and palpable pulses
• Ischemic ulcers are typically at the toes or heel margins, painful, pale/cyanotic, with absent pulses and cool skin
• Neuroischemic ulcers (most common in clinical practice) share both features
• Charcot neuroarthropathy can mimic infection - the key distinguishing test is elevation of the limb
• The probe-to-bone test is a critical bedside test - a negative result has a 96% negative predictive value for osteomyelitis
• HbA1c >7% is an independent risk factor for DFU development and post-surgical complications

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• Campbell's Operative Orthopaedics 15th Ed. 2026, Chapter 91 (Diabetic Foot - History and Physical Examination, Box 91.1)
• Current Surgical Therapy 14e (Evaluation of the Diabetic Foot - Wound, Ischemia, Infection, WIfI Classification)
• Bailey and Love's Short Practice of Surgery 28th Ed. (Diabetic Foot Infection, Chapter 43)
• Rosen's Emergency Medicine (The Diabetic Foot, Chapter 15)

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Muscles, Anatomy & High-Yield Memory Guide for Diabetic Foot Ulcer

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1. THE MUSCLE IMBALANCE CONCEPT (THE ROOT CAUSE of Deformity)

Weak intrinsic muscles become overpowered by stronger extrinsic muscles → deformity → abnormal pressure → callus → ulcer

• Campbell's Operative Orthopaedics 15e

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2. INTRINSIC MUSCLES OF THE FOOT (Weakened in DFU)

Dorsal Surface

Plantar Surface (4 Layers - know these)

Why Lumbricals and Interossei Matter Most

• Normally: lumbricals and interossei flex the MTP joint and extend the IP joints - keeping toes flat on the ground
• When these weaken: the long flexors (FDL, FDB) and long extensors (EDL) dominate unopposed
• Result: MTP hyperextension + IP flexion = claw toe or hammer toe
• The fat pad (under the metatarsal heads) migrates distally with the toes, exposing the metatarsal heads to direct plantar pressure
• This is why plantar metatarsal head ulcers are the most common site in neuropathic DFU

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3. EXTRINSIC MUSCLES (Remain Strong - Cause the Deformity)

Anterior Compartment (Dorsiflexors/Extensors)

Lateral Compartment (Everters)

Posterior Compartment - Superficial (Plantarflexors)

Gastrocnemius/soleus contracture (equinus deformity) is directly tested by the Silfverskiöld test and is a major contributor to forefoot plantar pressure and ulceration - Campbell's

Posterior Compartment - Deep (Toe Flexors/Invertors)

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4. THE DEFORMITY CHAIN - CONNECT THE DOTS

Motor neuropathy
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Intrinsic muscle wasting (especially lumbricals + interossei)
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Unopposed extrinsic muscle pull (EDL, FDL dominate)
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MTP hyperextension + IP flexion
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Claw toe / Hammer toe
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Distal migration of plantar fat pad
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Metatarsal heads exposed on plantar surface
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Repetitive pressure → Callus → Breakdown → Plantar ulcer

Gastrocnemius/soleus contracture (equinus)
        ↓
Increased forefoot plantar pressure
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Forefoot ulceration (especially metatarsal heads 1-5)

Autonomic neuropathy → loss of sweating (anhidrosis)
        ↓
Dry, cracked skin → portal of entry for bacteria
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Infection

Autonomic neuropathy → arteriovenous shunting in skin
        ↓
Decreased cutaneous perfusion + O₂ saturation
        ↓
Impaired wound healing + infection response

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5. NERVES TO KNOW (Motor Supply to the Foot)

In DFU, the tibial nerve supply to intrinsic plantar muscles is most clinically affected by the dying-back peripheral neuropathy of diabetes.

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6. COMMON ULCER SITES - LINKED TO ANATOMY

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7. KEY REFLEXES AND TESTS - WHAT THEY TEST

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8. THREE NEUROPATHIES - HIGH-YIELD SUMMARY

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9. NEUROPATHIC vs. ISCHEMIC ULCER - MASTER COMPARISON TABLE

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10. CHARCOT NEUROARTHROPATHY - DO NOT MISS

• Warm, red, swollen foot/ankle in a diabetic with peripheral neuropathy
• History of minor trauma (often forgotten)
• Relatively painless
• Blood glucose often normal, inflammatory markers normal or mildly raised

Elevate the limb - Charcot erythema and warmth subsides with elevation; infection does not - Campbell's Orthopaedics

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11. MEMORY MNEMONICS

"SINK" - Risk factors for DFU

• S - Sensory neuropathy (LOPS)
• I - Ischemia (PAD)
• N - Neuropathy (motor + autonomic)
• K - Know your footwear (ill-fitting shoes)

"VINE" - Differences in Neuropathy types

• Vibration + proprioception = large fibre
• Ill-fitting shoe goes unnoticed = sensory
• No sweating = autonomic
• Extensor digiti brevis atrophy = motor

Wagner grades - "Superficial, Deep, Bone, Gangrene x2"

• 0 = Pre-ulcer / healed
• 1 = Superficial ulcer
• 2 = Deep (tendon/capsule)
• 3 = Bone (osteomyelitis/abscess)
• 4 = Gangrene - local (toe/forefoot)
• 5 = Ganglrene - global (whole foot)

"PAD LOPS = BAD PROGNOSIS"

• PAD (peripheral arterial disease) + LOPS (loss of protective sensation) = 90x higher amputation risk when infection added

Probe-to-bone rule of 57/96

• 57% PPV for osteomyelitis if positive
• 96% NPV if negative (very useful to rule out)

Silfverskiöld test memory

• "Knee bends, gastrocnemius relents"
• When you bend the knee, gastrocnemius tension is relieved (it crosses the knee)
• If dorsiflexion improves with knee flexed = gastrocnemius tight (not Achilles)
• If dorsiflexion equally limited with knee bent and straight = Achilles contracture

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12. THE ESSENTIAL EXAMINATION SEQUENCE (Memory Framework)

S - Shoes (inspect first)
I - Inspect both feet (deformity, callus, ulcer)
N - Neurological (monofilament, vibration, pinprick, reflexes)
V - Vascular (pulses, ABI, temperature, Buerger's)
U - Ulcer assessment (size, depth, probe-to-bone)
L - Locomotion/ROM (Silfverskiöld test, toe joints)
A - Additional (skin, sweat, EDB atrophy)
R - Record and classify (Wagner/WIfI)

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• Campbell's Operative Orthopaedics 15e (Diabetic Foot, Basic Science + Physical Examination Box 91.1)
• Dermatology 2-Volume Set 5e (Pathogenesis of Diabetic Ulcers)
• Current Surgical Therapy 14e (Evaluation of the Diabetic Foot)

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LONG CASE: DIABETIC FOOT ULCER

A Complete Clinical Case for Medical Students and Postgraduates

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PATIENT IDENTIFICATION

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CHIEF COMPLAINT

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HISTORY OF PRESENTING ILLNESS (HOPI)

• Wound size has increased to approximately 3 cm × 2 cm
• Discharge is now thick, purulent, and foul-smelling
• Surrounding skin is red, warm, and swollen
• He denies feeling pain in the ulcer itself (due to neuropathy)
• He reports a dull aching in the right foot that is worse at night - he hangs the leg over the bedside for some relief (suggesting ischemic component)
• He has been limping but continues to bear weight on the affected foot
• No crepitus noticed

• Fever for the past 5 days: documented temperature of 38.4°C at home
• Chills and rigors: present, mild
• Reduced appetite over the past 2 weeks
• Increased thirst and urination over the past 3 weeks
• No vomiting
• No symptoms of upper respiratory tract infection

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SYSTEMIC REVIEW

• Exertional chest pain: none
• Palpitations: occasional, non-specific
• Leg pain on walking (claudication): YES - right calf pain after walking approximately 200 metres on flat ground, relieved by rest (intermittent claudication)
• Orthopnoea or PND: absent
• Ankle swelling: mild bilateral ankle oedema

• No cough, shortness of breath, or haemoptysis

• Nausea: mild, present
• Appetite reduced over past 2 weeks
• No diarrhoea or constipation
• Diabetic gastroparesis: uncertain (occasional bloating and fullness after meals)
• Bowel habit otherwise normal

• Polyuria: yes, for the past 3 weeks (waking 3 times at night)
• Polydipsia: yes
• No dysuria, haematuria, or frothy urine (no known proteinuria but not recently checked)
• Erectile dysfunction: present, for approximately 3 years (autonomic neuropathy feature)

• Bilateral foot numbness and tingling: present for approximately 5 years, worse at night
• "Walking on cotton wool" sensation: present
• No burning pain in feet (he had this 3 years ago but it has now gone - suggests progression to complete LOPS)
• No visual disturbance currently (but was told he has "background retinopathy" 2 years ago)
• Dizziness on standing up quickly (postural hypotension - autonomic neuropathy)
• No seizures, weakness of upper limbs, or speech difficulty

• Reduced mobility over past 3 months due to foot wound
• No joint pain in upper limbs
• Right foot deformity noted by patient

• Dry cracked skin on both heels (chronic)
• No other skin rashes

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PAST MEDICAL HISTORY

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PAST SURGICAL HISTORY

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DIET HISTORY

• Diet: mixed non-vegetarian diet
• Carbohydrate intake: HIGH - patient admits to eating white rice at least twice daily, bread, sugary tea (3-4 cups per day with 2 teaspoons of sugar each)
• Fruit and vegetable intake: low
• Compliant with diabetic diet: NO - not following dietitian advice
• Alcohol: denies current use (stopped 10 years ago, previously social drinker)
• Fluid intake: adequate
• Weight: 92 kg (obese)
• BMI: approximately 31 kg/m²

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ALLERGIC HISTORY

• Penicillin allergy: Yes - developed a maculopapular rash when given ampicillin 6 years ago
• No allergy to latex, iodine, or other medications
• No food allergies

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MEDICATION HISTORY

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FAMILY HISTORY

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SOCIAL HISTORY

• Occupation: Retired government officer (sedentary lifestyle for 15 years)
• Living situation: Lives with wife and adult son; has family support at home
• Smoking: Ex-smoker - smoked 20 cigarettes/day for 25 years; stopped 8 years ago (50 pack-years)
• Alcohol: Ex-drinker, stopped 10 years ago
• Exercise: Minimal - walks short distances only; no regular exercise
• Footwear: Wears ordinary closed leather shoes purchased from a regular shop; not custom-made or therapeutic
• Foot care: Does not inspect feet daily (cannot see them due to obesity and mild visual blurring); wife assists occasionally
• Mobility: Ambulatory with limp; uses a walking cane for the past 4 weeks
• Financial status: Middle income; has health insurance coverage
• Vaccination: No recent tetanus booster recalled

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PHYSICAL EXAMINATION

General Physical Examination

• Obese, middle-aged male
• Alert and oriented to time, place, and person
• In mild distress; right foot elevated on a pillow
• Appears unwell but not critically ill

• Sitting: 148/90 mmHg
• Standing: 132/78 mmHg
• Drop of 16 mmHg systolic = orthostatic hypotension (autonomic neuropathy)

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Head and Neck

• Anicteric sclerae
• No pallor (conjunctival)
• Dry mucous membranes (hyperglycaemia)
• No cervical lymphadenopathy
• Fundoscopy not performed at bedside (ophthalmology to review)

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Cardiovascular Examination

• Pulse: 96 bpm, regular, good volume bilaterally in upper limbs
• JVP: not elevated
• Apex beat: 5th intercostal space, mid-clavicular line (not displaced)
• Heart sounds: S1 and S2 present, no murmurs
• No pericardial rub

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Respiratory Examination

• Chest expansion: equal bilaterally
• Percussion: resonant throughout
• Auscultation: vesicular breath sounds, no added sounds
• No features of pulmonary oedema

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Abdominal Examination

• Abdomen: soft, obese, non-tender
• No hepatomegaly or splenomegaly
• Appendicectomy scar: present, well-healed, right iliac fossa
• No renal angle tenderness
• Bowel sounds: present and normal

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Lymph Node Examination

• Right inguinal lymph nodes: palpable, enlarged, tender (reactive to right foot infection)
• Left inguinal: not enlarged
• No axillary or cervical lymphadenopathy

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LOWER LIMB EXAMINATION (Detailed - Right vs. Left)

SHOE INSPECTION

• Ordinary closed leather shoes, right shoe worn more medially
• No custom insoles or therapeutic footwear
• Seam visible on the inner right shoe lateral side where the 5th toe used to be
• Abnormal wear pattern on the right sole: increased under the 1st metatarsal head area

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GENERAL INSPECTION OF BOTH FEET

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ULCER ASSESSMENT (RIGHT FOOT)

• Erythema extending 2.5 cm beyond the wound margin (cellulitis)
• Warmth and induration
• No crepitus on palpation (no gas-forming organisms)
• Callus thickened, moist, and malodorous

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VASCULAR ASSESSMENT

• Right hallux: >4 seconds (markedly prolonged - ischemia)
• Left hallux: 3 seconds (prolonged)

• Elevation to 45° for 2 minutes: pallor appears within 90 seconds
• Lowering to dependent position: sluggish dependent rubor after 3 minutes
• Buerger's angle: approximately 30° (positive; significant ischemia)

• Right ABI 0.42 = severe peripheral arterial disease (critical ischemia threshold)
• Left ABI 0.64 = moderate PAD

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NEUROLOGICAL ASSESSMENT

• Right hallux: absent
• Right medial malleolus: absent
• Left hallux: reduced (feels vibration for 4 seconds vs. 18 seconds on examiner's finger)

• Right foot: absent below ankle
• Left foot: reduced below ankle

• Right foot: unable to distinguish warm from cold
• Left foot: reduced

• Right hallux: absent (cannot detect up/down movement)
• Left hallux: reduced

• Right: absent
• Left: absent

• Bilateral: present but reduced

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RANGE OF MOTION - SILFVERSKIÖLD TEST (Right)

• Ankle dorsiflexion with knee extended: -5° (5° plantarflexion - cannot get to neutral)
• Ankle dorsiflexion with knee flexed 90°: +8° (improves significantly)
• Interpretation: Gastrocnemius contracture (equinus) on the right - contributing to increased forefoot plantar pressure and 1st metatarsal head ulceration

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MOTOR EXAMINATION

• Tibialis anterior (L4): 4/5 bilaterally
• Extensor hallucis longus (L5): 4/5 right, 4/5 left
• Peronei (L5/S1): 4/5 bilaterally
• Gastrocnemius/soleus (S1/S2): 4+/5 bilaterally
• Toe flexion and extension: reduced (3/5) all toes, right foot
• EDB atrophy: visible and confirmed by palpation bilaterally (sign of motor neuropathy)

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Charcot Assessment

• No acute Charcot changes currently present
• No acute bony swelling or marked warmth of ankle/midfoot
• Old 5th toe amputation stump well-healed

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SUMMARY OF FINDINGS

1. Plantar ulcer right 1st MTH: 3.2 × 2.1 cm, punched-out, callus-surrounded, purulent discharge, probe-to-bone positive
2. Surrounding cellulitis 2.5 cm, early lymphangitis
3. Systemic infection: fever 38.5°C, tachycardia 96 bpm, hyperglycaemia 18.4 mmol/L
4. Complete loss of protective sensation both feet (10-g monofilament)
5. Severe PAD right foot: absent posterior tibial and dorsalis pedis pulses, ABI 0.42, positive Buerger's test
6. Gastrocnemius contracture: Silfverskiöld positive right foot
7. Motor neuropathy: EDB atrophy, claw toes 2nd-4th right, hammer toe 4th left
8. Autonomic neuropathy: anhidrosis, orthostatic hypotension, erectile dysfunction

• Wagner Grade 3 (deep ulcer with suspected osteomyelitis)
• University of Texas: Grade 3D (deep ulcer + infection + ischemia)
• WIfI Stage: W2, I3, fI2 (wound grade 2, severe ischemia, moderate foot infection) → High amputation risk; revascularisation likely to benefit

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INVESTIGATIONS

Bedside

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Haematology

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Biochemistry

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Microbiology

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Radiology

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MANAGEMENT

Immediate (Acute Admission - First 24-48 hours)

• Bed rest, right foot elevated
• Patient must NOT bear weight on affected foot

• Two large-bore IV cannulae
• IV normal saline (adjust for CKD - careful fluid balance)

• Stop oral hypoglycaemics (CKD - metformin contraindicated at eGFR <30; risk worsens)
• IV insulin sliding scale protocol to achieve BG 7-10 mmol/L
• Endocrinology referral for long-term insulin optimisation
• Target HbA1c <8% (more liberal given co-morbidities per current evidence)

• Note: patient has penicillin allergy (maculopapular rash to ampicillin)
• Avoid beta-lactams/penicillins
• Empirical regimen (severe infected DFU with suspected osteomyelitis):
  • IV Vancomycin 15 mg/kg q12h (gram-positive cover including MRSA) - dose-adjust for CKD (renal function guided dosing)
  • IV Metronidazole 500 mg q8h (anaerobic cover)
  • IV Ciprofloxacin 400 mg q12h (gram-negative including Pseudomonas cover) - dose-adjust for CKD
• Switch to culture-guided therapy once results available (5-7 days)
• Duration: if bone resected with clear margins: 2-3 weeks; if bone infected and not fully resected: 4-6 weeks IV then oral

• Bedside debridement of callus and necrotic tissue (surgical team)
• Normal saline wound irrigation
• Moist wound dressing: non-adherent dressing with antimicrobial cover
• Daily wound review with wound size documentation
• Mark cellulitis margins with a skin marker pen to monitor spread

• Paracetamol 1g QDS regular (safe in CKD)
• Avoid NSAIDs (CKD, cardiovascular disease)
• If neuropathic pain present: consider Pregabalin (dose-reduce in CKD) or Amitriptyline low dose

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Surgical Management

1. Surgical debridement: formal theatre debridement of necrotic tissue, infected bone, and collection under anaesthesia
2. Bone biopsy at time of debridement: send for histology and culture (gold standard osteomyelitis diagnosis)
3. Vascular surgery review: CTA findings to guide revascularisation
   • Right ABI 0.42: severe ischemia - wound will not heal without revascularisation
   • Options: percutaneous transluminal angioplasty (PTA) of tibial vessels (first choice, less invasive) or bypass surgery (if anatomy suitable)
   • Revascularisation should precede or accompany definitive wound surgery where possible
4. Possible ray amputation (resection of 1st metatarsal + toe) if bone and soft tissue non-salvageable
5. Silfverskiöld test positive → Consider surgical gastrocnemius lengthening or percutaneous Achilles tendon lengthening at a later stage to reduce forefoot plantar pressure

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Medical Management (Ongoing)

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Multidisciplinary Team (MDT) Referrals

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Long-Term Prevention and Foot Care Education

• Custom therapeutic footwear with extra-depth toe box and moulded insoles (once healed)
• Daily foot inspection: patient + wife (given visual blurring); use of a foot mirror
• No barefoot walking at any time (indoors or outdoors)
• Annual comprehensive foot examination
• Monofilament testing at every diabetic review appointment
• Regular podiatry: nail care, callus debridement (every 6-8 weeks minimum)
• Smoking cessation: already achieved (8 years) - reinforce and document
• Glycaemic education: structured diabetes education programme
• Stocking/footwear advice: no tight elastic socks, no synthetic non-breathable materials

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PROGNOSIS

• Wagner Grade 3 + University of Texas Grade 3D (infection + ischemia): carries a 40-55% risk of amputation without optimal management
• ABI 0.42: wound healing unlikely without revascularisation
• Positive probe-to-bone: confirmed osteomyelitis likely; will require surgical bone debridement
• With optimal multidisciplinary management (revascularisation + debridement + glycaemic control + offloading): amputation-free survival achievable in approximately 65-70% of cases

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DIABETIC FOOT ULCER

Complete History Taking + Expanded Physical Examination + Investigations + Management

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PART 1: HISTORY TAKING

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1. PATIENT IDENTIFICATION

• Full name
• Age / Date of birth
• Sex
• Occupation (current and past - standing/walking occupations increase DFU risk)
• Address (urban vs. rural = access to care)
• Referred by (GP, A&E, community nurse)
• Informant and reliability

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2. CHIEF COMPLAINT

"I have a wound on the bottom of my foot that is not getting better, for 3 months."

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3. HISTORY OF PRESENTING ILLNESS (HOPI)

• Exact location of the wound: plantar (sole), dorsum, toes, heel, interdigital, malleolus
• Which foot: right, left, or bilateral?
• Which specific anatomical area: metatarsal head, toe tip, heel, arch

• How did it start? (blister, callus that broke down, cut, burn, pressure sore, spontaneous)
• Was there any preceding trauma? (patient may deny injury - ask specifically about new shoes, foreign body, stepping on something)
• Was it noticed by the patient or by someone else? (if found by another person = complete LOPS - clinically significant)

• Nature of the wound: open, closed blister, crack
• Painless or painful?
  • Painless ulcer = sensory neuropathy (commonest)
  • Painful ulcer = ischemia, infection, or intact sensation
  • Night pain worse at rest, relieved by hanging leg = ischemic rest pain

• Has the wound increased in size?
• Is surrounding redness spreading (cellulitis)?
• Any red lines tracking up the leg (lymphangitis)?

• Discharge: yes/no, colour (clear, yellow, green, brown), consistency (watery, thick purulent), smell (foul = infection/anaerobes)
• Swelling: local or spreading
• Warmth
• Fever, chills, rigors (systemic sepsis)
• New confusion or deterioration in elderly diabetics = sepsis until proven otherwise

• Duration of ulcer
• Speed of progression: slow (weeks/months - neuropathic) vs. rapid (days - infected/ischemic)
• Any prior healing and re-breakdown at same site?

• Weight bearing makes it worse (pressure)
• Elevation relieves ischemic pain
• Rest relieves claudication
• Tight footwear exacerbates

• Impact on mobility: walking with limp? Completely non-weight-bearing?
• Impact on daily activities, sleep
• Prior visits to GP/hospital for this wound - treatments tried (antibiotics, dressings, debridement)

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4. DIABETES HISTORY (Dedicated Section)

• Type of DM: Type 1 or Type 2
• Duration of diagnosis
• How was it diagnosed? (symptoms, routine screening, incidental finding)
• Current medications: insulin (type, dose, timing), oral agents
• Glycaemic control:
  • Most recent HbA1c and date
  • Home blood glucose monitoring frequency and values
  • Frequency of hypoglycaemic episodes
• Compliance: missing doses? Dose adjustment by patient?
• Dietary adherence: following diabetic diet?
• Regular monitoring appointments (diabetic clinic, GP)

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5. FOOT-SPECIFIC HISTORY

• Previous ulcers: number of episodes, sites, how they healed, time to heal
• Previous foot infections requiring hospitalisation
• Previous amputations: level (toe, ray, transmetatarsal, below-knee, above-knee), side, year, reason
• History of Charcot neuroarthropathy: sudden hot swollen foot/ankle in the past
• Footwear: type normally worn (open sandals, closed shoes, slippers), custom therapeutic footwear, fitting
• Daily foot care routine: does the patient inspect their own feet daily? Can they reach their feet? Do they use a mirror?
• Nail care: who cuts nails, how (clippers or scissors - important to ask)
• Previous callus removal or podiatry visits
• Any history of foreign body in the shoe unnoticed (classic neuropathy story)

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6. NEUROPATHY SYMPTOMS

• Numbness: feet, ankles, legs - how far up does it go?
• Tingling / "pins and needles"
• Burning, shooting, electric pains (small fibre neuropathy - these are early symptoms)
• Loss of burning sensation in feet (absent pain when stepping on hot surface = LOPS)
• "Walking on cotton wool" or "walking on pebbles" sensation
• Unsteadiness in the dark (proprioceptive loss)
• Duration of symptoms

• Has foot shape changed?
• Difficulty walking, tripping, foot drop
• Weakness in ankles or toes

• Dry feet (no sweating): a direct question since patients rarely volunteer this
• Dizziness on standing (postural hypotension)
• Bloating, nausea, fullness after small meals (gastroparesis)
• Diarrhoea alternating with constipation (autonomic gut)
• Erectile dysfunction (men) / female sexual dysfunction
• Urinary retention or incontinence (neurogenic bladder)
• Palpitations (cardiac autonomic neuropathy)

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7. VASCULAR / ISCHEMIA HISTORY

• Leg pain on walking: which muscles? (calf = SFA disease; thigh/buttock = aortoiliac disease)
• Claudication distance: how far can the patient walk before pain starts?
• Does pain resolve within 2-3 minutes of rest? (claudication) vs. persists longer?
• Rest pain: pain in toes/forefoot at rest, worse at night, relieved by hanging leg out of bed (critical ischemia)
• Previous vascular surgery: angioplasty, stenting, bypass
• Cold feet: persistent, one side worse than other?
• Colour changes: pallor, blueness of toes
• Smoking history: current/ex, how many cigarettes per day, for how many years (pack-years = packs/day × years)
• Previous MI, stroke, TIA, or angina (systemic atherosclerosis)

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8. SYSTEMIC REVIEW

• Chest pain, shortness of breath on exertion, orthopnoea, PND
• Palpitations
• Ankle swelling

• Cough, shortness of breath
• Important if patient will need surgery/anaesthesia

• Nausea, vomiting, reduced appetite (infection, uraemia)
• Bowel habit change
• Weight loss (malnutrition = impaired wound healing)

• Polyuria, polydipsia (hyperglycaemia)
• Frothy urine (proteinuria = nephropathy)
• Reduced urine output (AKI on CKD in sepsis)

• Visual changes, blurring (retinopathy)
• Inability to inspect feet due to poor vision - a safety concern

• Fever, chills, rigors
• Confusion in elderly (septic encephalopathy)

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9. PAST MEDICAL HISTORY (PMH)

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10. PAST SURGICAL HISTORY (PSH)

• Previous amputations (level, side, year)
• Vascular procedures (angioplasty, bypass)
• Any foot/ankle surgeries
• Any other surgeries and complications

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11. DRUG AND ALLERGY HISTORY

• Antidiabetic agents: metformin, sulfonylureas, SGLT2 inhibitors, GLP-1 agonists, insulin (type + dose + timing)
• Antihypertensives: ACE inhibitors, ARBs, calcium channel blockers, beta-blockers
• Antiplatelet agents: aspirin, clopidogrel
• Statins
• Anticoagulants (warfarin, DOAC): important for surgical planning
• Steroids or immunosuppressants: impair healing and mask infection signs
• Any recent antibiotics: which ones, duration, response - critical for culture interpretation

• Drug allergies: specify drug name AND type of reaction (rash, anaphylaxis, GI upset)
• Penicillin allergy: very common, affects antibiotic choice
• Latex allergy (relevant for theatre)
• Iodine/antiseptic allergy

• Are medications taken regularly?
• Any recent changes in dosing?

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12. DIET AND NUTRITIONAL HISTORY

• Type of diet: vegetarian, non-vegetarian, mixed
• Carbohydrate intake: rice, bread, sugary drinks, sweets
• Protein intake: meat, fish, eggs, dairy (albumin <30 = poor healing prognosis)
• Fruit and vegetable intake
• Fluid intake
• Alcohol: type, frequency, quantity (units/week)
• Following diabetic diet advice: yes/no
• Seen a dietitian? How long ago?
• Appetite: reduced recently? (chronic illness, infection, depression)
• Recent unintentional weight loss?

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13. FAMILY HISTORY

• Diabetes mellitus in parents, siblings, children
• Peripheral vascular disease, cardiovascular disease
• Lower limb amputations in family members
• Hypertension, stroke, renal disease

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14. SOCIAL HISTORY

• Occupation: seated desk job vs. standing/walking job
• Retired or working?
• Living alone or with family - crucial for wound care compliance and follow-up
• Home support: is anyone able to assist with foot inspection, dressing changes?
• Ability to attend clinic: transport, mobility
• Smoking: current, ex, never; pack-years
• Alcohol: units/week
• Exercise level: minimal, moderate, active
• Ability to inspect own feet: limited by obesity? Reduced vision?
• Financial status and insurance: impacts access to custom footwear, podiatry, specialist care
• Tetanus vaccination status

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PART 2: PHYSICAL EXAMINATION (FULLY EXPANDED)

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STEP 1: GENERAL INSPECTION (Before touching the patient)

• Level of consciousness and orientation
• Facial appearance: flushed (fever), pale (anaemia), grimacing (pain vs. expressionless in neuropathy)
• Body habitus: obesity (BMI estimate)
• Obvious distress: patient holding or elevating affected foot
• Sitting position: is the affected leg elevated or dependent?
• Prosthetics visible on the bed
• Wound dressing or bandaging already in place
• Walking aids present: crutches, wheelchair, walking frame, cane
• Smell: foul odour from wound (anaerobic or polymicrobial infection)

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STEP 2: VITAL SIGNS

• Drop of >20 mmHg systolic or >10 mmHg diastolic = orthostatic hypotension = autonomic neuropathy

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STEP 3: SHOE AND FOOTWEAR INSPECTION (Before removing shoes)

• Type of shoe: open sandal, closed shoe, trainer, slipper, therapeutic shoe
• Size: is it the correct size? Too small = pressure over bony prominences
• Toe box depth and width: must accommodate toe deformities
• Seams or ridges on the inner surface that the patient cannot feel (a foreign body inside a shoe that causes an ulcer = hallmark of LOPS)
• Sole wear pattern:
  • Uniform wear = normal
  • Excessive wear under 1st MTH = hallux valgus, equinus
  • Lateral sole wear = supination/cavus foot
  • Medial sole wear = pronation/flatfoot
• Any blood staining or discharge on the inner lining
• Insoles: present? Custom-moulded?

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STEP 4: LOWER LIMB INSPECTION (Both feet - shoes and socks removed)

A. Overall Lower Limb Look

• Compare both limbs side by side
• Look from the front, side, and then sole (use a foot mirror or ask patient to lift foot)
• Note the general colour, size difference, swelling

B. Deformities

C. Muscle Wasting (Visible)

• Extensor digitorum brevis (EDB): small mound on the dorsolateral aspect of the foot. Atrophy = visible hollowing in this area = motor neuropathy sign. This is the most visible intrinsic muscle of the foot.
• Interossei wasting: deep grooves between the metatarsals on the dorsum of the foot (interosseous guttering)
• Calf muscle wasting: compared bilaterally (measure calf circumference at the same level if asymmetric)
• Intrinsic wasting = "intrinsic minus" foot = the mechanism of claw toes

D. Skin and Nail Changes

E. Colour Changes on Elevation and Dependency

• Elevation test: raise the leg to 45° for 60 seconds
  • Normal: slight pallor
  • Ischemic: rapid pallor within 30-60 seconds (Buerger's positive)
• Dependency test: sit the patient upright and let leg hang
  • Normal: returns to normal colour in <10 seconds
  • Ischemia: slow return + dependent rubor (reactive hyperaemia) = confirms ischemia
  • Buerger's angle: the angle at which pallor appears on elevation (normal = 90°; <30° = critical ischemia)

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STEP 5: PALPATION OF THE FOOT

A. Skin Temperature

• Use the back of your hand
• Start proximally and work distally
• Compare corresponding levels bilaterally
• Neuropathic foot: warm throughout (AV shunting)
• Ischemic foot: cool, especially distally
• Infected area: localised warmth
• Charcot foot: warm, diffuse, bounding warmth
• Document: warm/cool/cold; any asymmetry

B. Pulse Palpation (Four Pulses in Both Legs)

• 0 = absent
• 1+ = weak/diminished
• 2+ = normal
• 3+ = bounding

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STEP 6: VASCULAR ASSESSMENT (In Detail)

A. Capillary Refill Time (CRT)

• Press the pulp of the hallux firmly for 5 seconds until white
• Release and count seconds until colour returns
• Normal: ≤2 seconds
• Prolonged >2 seconds = impaired perfusion

• 4 seconds = significant ischemia

• Assess at toes, dorsum of foot, and shin

B. Buerger's Test (Fully Described)

• Normal: slight pallor only
• Ischemia: pallor appears within 1-2 minutes (note which angle this occurs at = Buerger's angle)
• Buerger's angle <30° = critical ischemia

• Normal: pink colour returns within 5-10 seconds
• Ischemia: dusky pallor first, then slow spread of dependent rubor (brick-red/dark red) over 1-3 minutes
• This rubor = reactive hyperaemia from maximal vasodilation in ischemic tissue
• A positive Buerger's test = pallor on elevation + dependent rubor on lowering = confirms significant ischemia

C. Ankle-Brachial Index (ABI) - Step by Step

1. Patient lies supine for 10 minutes
2. Place cuff around right upper arm; apply Doppler gel over brachial artery
3. Inflate cuff above systolic; slowly deflate; record pressure at which Doppler signal returns = right brachial systolic BP
4. Repeat on left arm; use the higher of the two brachial readings
5. Place cuff just above the right ankle; apply Doppler gel
6. Identify posterior tibial artery signal; inflate cuff and deflate; record pressure = right ankle (PT) systolic
7. Repeat for dorsalis pedis
8. Use the higher of PT or DP as the ankle pressure

• Used when ABI >1.3 (calcified vessels)
• TBI <0.7 = PAD
• TBI <0.15 = critical ischemia
• More reliable in diabetics

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STEP 7: ULCER ASSESSMENT (Systematic 10-Point Evaluation)

• Exactly where: plantar 1st MTH, tip of hallux, dorsal PIP, heel, malleolus, interdigital
• Neuropathic: plantar pressure points (MTHs, heel)
• Ischemic: distal (toe tips, margins, heel)
• Venous (not DFU but must exclude): gaiter zone (medial lower leg)

• Single or multiple ulcers?
• Multiple ulcers at different pressure points = motor neuropathy + high plantar pressure

• Measure longest dimension × widest perpendicular dimension
• Document in cm²
• Repeat at every visit to track healing progress

• 50% reduction in size at 4 weeks = good prognostic indicator for healing

• Round, oval, irregular
• Punched-out = neuropathic
• Irregular / serpiginous edges = ischemic or infected

• Callus surrounding = neuropathic (chronic pressure)
• Undermined edges = deep tracking infection or Buruli ulcer
• Raised, rolled edges = may indicate malignancy (Marjolin's ulcer in chronic wounds)
• Sloping edges = healing margin
• Punched-out vertical edges = ischemic

• Superficial (skin only - Wagner 1)
• Deep (subcutaneous tissue - Wagner 1-2)
• Tendon/capsule visible (Wagner 2)
• Bone visible or palpable (Wagner 3)

• Use a sterile blunt metal probe or a sterile cotton swab
• Gently probe the wound base and walls
• Feel for firm, gritty resistance = bone contact
• Positive probe-to-bone = 57% positive predictive value for osteomyelitis
• Negative probe-to-bone = 96% negative predictive value (rules out osteomyelitis)
• Also probe for sinuses, tracts, undermining

• Erythema: measure and mark extent with a skin marker pen (to track cellulitis spread)
• Induration: hard, woody consistency = deep infection, necrotising fasciitis risk
• Warmth: localised (infection) vs. diffuse (Charcot)
• Oedema: pitting or non-pitting
• Maceration: excessive moisture
• Crepitus on palpation: CRITICAL SIGN - gas in tissue = gas-forming organisms (Clostridia, E. coli, Klebsiella) = surgical emergency
• Lymphangitic streaking: red lines tracking proximally = lymphangitis

• Amount: scanty, moderate, copious
• Colour: clear/serous, straw-coloured, yellow, green (Pseudomonas), brown, bloody
• Consistency: watery, purulent, thick
• Smell: odourless, mild, foul (anaerobes), sweetish (Pseudomonas = grape-like smell)

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STEP 8: NEUROLOGICAL EXAMINATION (Four Modalities)

A. Large Fibre Sensory (Aβ fibres)

• Calibrated filament that buckles at exactly 10 g of pressure
• Patient closes eyes or looks away
• Apply perpendicular to skin until filament bends (takes about 1-2 seconds)
• Do NOT apply over callus, ulcer, or scarred skin (test nearby normal skin)
• Do NOT test in a rhythmic predictable pattern (patient will anticipate)
• Ask: "Do you feel this? If so, where?" (yes/no response)

1. Plantar surface of hallux
2. Plantar surface of 3rd toe
3. Plantar surface of 5th toe
4. Plantar 1st metatarsal head
5. Plantar 3rd metatarsal head
6. Plantar 5th metatarsal head
7. Plantar midfoot (medial)
8. Plantar midfoot (lateral)
9. Plantar heel (medial)
10. Dorsal 1st web space

• 10/10 = normal
• <8/10 = loss of protective sensation (LOPS) = at risk
• Complete failure to feel any site = severe LOPS = very high ulcer risk

• Strike the 128 Hz tuning fork against the heel of your hand
• Apply the base to the bony prominence of the great toe (IP joint) first
• Ask: "Do you feel a buzzing/vibrating sensation? Tell me when it stops."
• Note the duration the patient feels vibration vs. how long you feel it on your own finger = comparison
• If absent at hallux, move to medial malleolus, then tibial tuberosity, then iliac crest (ascending)
• Vibration loss is one of the earliest signs of large fibre neuropathy

• Hold the sides of the hallux between your thumb and index finger (not the top and bottom - that gives pressure cues)
• Move the toe up or down in small increments (start with a large movement, reduce to small)
• Patient closes eyes: ask "Is the toe pointing up or down?"
• Normal: detects movement of 1-2 mm
• Impaired proprioception = risk of falls, Charcot neuroarthropathy

B. Small Fibre Sensory (Aδ and C fibres)

• Use a Neurotip or clean safety pin
• Apply gently to the dorsum of the foot (proximal to distal)
• Ask: "Is this sharp or dull?"
• Compare corresponding areas bilaterally
• Glove-and-stocking distribution loss = typical peripheral neuropathy

• Use a Tip-Therm device or two test tubes (one filled with warm water ~40°C, one cold/ice water)
• Apply alternately to the dorsum of foot and sole
• Ask: "Is this warm or cold?"
• Reduced temperature discrimination = small fibre neuropathy
• Often lost before vibration in early DM neuropathy

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STEP 9: REFLEXES

• Ankle jerk absent bilaterally = peripheral neuropathy (highly sensitive)
• Knee jerk reduced = more severe or proximal neuropathy
• If reflexes absent, consider reinforcement (Jendrassik manoeuvre) before recording as absent

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STEP 10: RANGE OF MOTION - SILFVERSKIÖLD TEST

1. Lay the patient supine
2. Support the subtalar joint in neutral (slight eversion)
3. Measure passive ankle dorsiflexion with the knee fully extended (gastrocnemius is stretched - it crosses both knee and ankle)
4. Measure again with the knee flexed to 90° (gastrocnemius is relaxed, only Achilles remains tensioned)

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STEP 11: SYSTEMIC EXAMINATION

Lymph Nodes

• Inguinal lymph nodes (bilateral): palpate for size, tenderness, consistency
• Tender, enlarged inguinal nodes = reactive to lower limb infection
• Document size in cm

Cardiovascular

• Auscultate heart sounds: S1, S2, murmurs
• Check JVP
• Assess for heart failure (bilateral ankle oedema, crackles at lung bases, raised JVP)

Abdominal

• Aortic aneurysm: palpate for expansile pulsatile mass midline (associated with PAD)
• Renal size: enlarged = polycystic kidney disease (can be associated with DM)
• Scars from previous surgery

Eyes (if possible)

• Note: formal fundoscopy is done by ophthalmology; however, document any obvious visual impairment as it directly impacts ability to inspect feet

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PART 3: INVESTIGATIONS

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Bedside

Haematology

Biochemistry

Microbiology

Radiology

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PART 4: MANAGEMENT

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The Five Pillars of DFU Management

"DANCE": Debridement + Antibiotics + Neuropathy management + Circulation (revascularisation) + Education/offloading

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Pillar 1: Glycaemic Control

• Admit if RBS >15 mmol/L with active infection
• Withhold metformin if eGFR <30 or contrast needed
• IV insulin sliding scale protocol (target BG 7-10 mmol/L inpatient)
• Endocrinology referral for optimisation
• Discharge with clear insulin instructions and HbA1c target <7-8%

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Pillar 2: Offloading Pressure

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Pillar 3: Wound Care and Debridement

• Sharp surgical debridement: remove all callus, necrotic tissue, fibrinous slough, and infected material; creates a clean wound base to stimulate healing
• Wound irrigation: normal saline
• Dressings: match dressing to wound moisture level:
  • Dry/necrotic wound: hydrogel dressings (donate moisture)
  • Moderate exudate: foam dressings
  • Infected: silver-impregnated, iodine, or honey-based antimicrobial dressings
  • Heavily exuding: alginate dressings
• Biofilm management: biofilm (organised bacterial colonies) must be disrupted by debridement; no antibiotic penetrates intact biofilm
• Negative pressure wound therapy (NPWT/VAC): for large wounds post-debridement; promotes granulation tissue formation
• Biological agents: Becaplermin (PDGF) gel for chronic non-healing neuropathic ulcers

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Pillar 4: Infection and Antibiotic Management

• No recent antibiotics: cover gram-positive cocci (Strep, MSSA) - flucloxacillin OR clindamycin
• Recent antibiotics: expand to cover gram-negatives - add fluoroquinolone or co-amoxiclav
• Severe/limb-threatening: broad-spectrum including MRSA and Pseudomonas cover:
  • Vancomycin (MRSA) + piperacillin-tazobactam (gram-negatives + Pseudomonas) + metronidazole (anaerobes)
  • If penicillin allergic: vancomycin + ciprofloxacin + metronidazole
• Switch to culture-directed therapy at 48-72 hours
• Duration: mild = 7-14 days oral; moderate = 2-3 weeks; osteomyelitis = 4-6 weeks (IV then oral)

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Pillar 5: Revascularisation (if ABI <0.7 or absent pulses)

• Vascular surgery referral is mandatory if pulses absent or ABI <0.7
• Pre-operative imaging: CTA or MRA for arterial mapping
• Options:
  • Endovascular (angioplasty ± stenting): minimally invasive; first-line for tibial/peroneal disease in DFU
  • Surgical bypass: femoral-popliteal, femoral-tibial, femoral-peroneal; for long segment occlusions
• Target: restoration of pulsatile flow to the foot to enable wound healing
• Without revascularisation: ABI <0.4 = wound will not heal regardless of antibiotics or dressings

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Surgical Options for Osteomyelitis

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MDT Referrals Summary

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Long-Term Prevention

• Custom therapeutic footwear: extra-depth, wide toe box, moulded insoles permanently after a healed ulcer
• Annual comprehensive foot review (monofilament, ABI, structural exam)
• Daily foot self-inspection (patient + carer if vision impaired)
• Regular podiatry every 6-8 weeks minimum
• HbA1c optimisation
• Smoking cessation
• Structured diabetic education programme

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