Offloading Diabetic Foot Ulcers

Andrew BernhardClass of 2013

Chronic wound caused by neuropathy and pressure

Sensory, motor, and autonomic neuropathies possible

Often seen over boney prominences or in areas of increased pressure, sometimes due to shoe pressure

Generally painless Hyperkeratotic rim with moist base

Diabetic Foot Ulcers

Wagner System – Grades 0–6, No open lesion – gangrene

UTHS – Two parts based on grade (0-3) and stage (A-D)

PEDIS – Perfusion, Extent, Depth, Infection, Sensation

NPUAP – Most common classification, Stages 1-4

Staging of Ulcers

Ulcer Examples

Ulcer Examples

Ulcer Examples

Ulcer Examples

Ulcer Examples

Aggressive debridement is key to helping wound

Surgical debridement, or incision and drainage, are often required

Correcting blood sugar correlates with decreased ulcer incidence

Offloading the foot will also decrease recurrence and speed up recovery

Ulcer Treatment

Various devices are available to offload the foot

The gold standard is the Total Contact Cast Removable Cast Walkers are also a

possibility Diabetic shoes are generally good for healed

ulcers

Offloading of Diabetic Ulcers

Gold standard for ulcer treatment Transfer weight of lower extremity

from foot to lower leg, by 1/3 45% reduction in forefoot loading Contraindicated in heel ulcers, infection,

poor skin quality, arterial insufficiency

Changed weekly for 6 weeks Very rarely used (1.7% of ulcers)

Total Contact Cast

Alternative to Total Contact Cast Cheaper More attractive to patient Better visibility of wound Poor patient compliance, due

to removability

Removable Cast Walkers

More used to control ankle motion Not necessarily designed for ulcer treatment Can provide offloading, similar to an RCW or

TCC Still removable, so compliance is decreased

CAM Walker

Good choice – Charcot Restraint Orthotic Walker

Fully padded interior with hard, immobile exterior

Covers entire foot and lower leg Patient needs to acclimate to the boot, one

hour at a time

CROW Walker

CROW Walkers

Orthowedge – unloads forefoot completely Heelwedge – good for unloading heel Medsurg / Surgical Shoe Wound Care Shoe System

Darco products

Other options

Wu, Stephanie, et. al. “Use of Pressure Offloading Devices in Diabetic Foot Ulcers: Do we practice what we preach?” Diabetes Care. 2008 November; 31(11): 2118–2119

Kushner, Donald. “The Diabetic Foot.” OCPM Lecture Cavanagh, Peter, et. al. “Treatment for diabetic foot

ulcer” Lancet. 2005; 366: 1725–35 Darco Products -

http://www.darcointernational.com/off-loading-wound-care

References