Peripheral neuropathy remains the commonest pathogenesis of foot ulcers in patients with diabetes, yet ischemic ulcers represent an increasing burden of morbidity—non-healing, infection, amputation—and even mortality.¹
The unfortunate reference to “diabetic foot”, characteristically represents the classical triad of: neuropathy, ischemia, and infection.² That some element of neuropathy is a given, clinical assessment focuses then on determining if one or both of ischaemia and infection are present and the depth of such involvement: superficial; penetrating to tendon or capsule; or penetrating to bone or joint.²
Causes of Ischaemic Foot Ulceration
Large artery obstruction
- atherosclerosis
- embolism
Small artery obliteration
- Raynaud’s disease
- Scleroderma / Rheumatoid arthritis (vasculitis)
- Buerger’s Disease (thromboangiitis obliterans) – males 20-40 years old
- Embolism – “Trash foot” syndrome
- Diabetes mellitus
- Physical agents
- pressure necrosis
- radiation
- trauma, electrical burns
In the context of diabetes, a chronic discharging sinus and sausage-like appearance to the toe are the hallmarks of osteomyelitis: a sterile metal probe inserted into the ulcer that penetrates to bone all but confirms the diagnosis. Look for focal osteopenia, cortical erosions, or a periosteal reaction (early) vs. sequestration (late) on plain X-Ray, while MRI is the confirmatory imaging modality of choice.²
- Ndip, Agbor, and Edward B. Jude. “Emerging Evidence for Neuroischemic Diabetic Foot Ulcers: Model of Care and How to Adapt Practice.” The International Journal of Lower Extremity Wounds 8, no. 2 (June 2009): 82–94. https://doi.org/10.1177/1534734609336948.
- Sharad P. “Understanding diabetic foot.” International journal of diabetes in developing countries vol. 30,2 (2010): 75-9. doi:10.4103/0973-3930.62596.
