Debridement of the neuropathic ulcer

Debridement is the most important part of wound control. It is not possible to assess a neuropathic ulcer properly without removing all associated callus. Sometimes the presence of the ulcer will only be determined following removal of callus which exposes a hitherto unsuspected lesion.

If an ulcer is suspected the patient should always be warned before the overlying callus is removed because he may otherwise feel that it was the callus removal that caused the ulcer.

Rationale

• Removes callus, thus lowering plantar pressures

• Enables the true dimensions of the ulcer to be seen

• Stimulates ulcer healing

• Removes any physical barrier to growth of new epithelium across the ulcer from the margin

• Prevents callus from sealing off an ulcer, which would prevent drainage and promote infection

• Enables drainage of exudate and removal of dead tissue (this renders infection less likely by reducing bacterial load and removing material which is a suitable growth medium for bacteria)

• Enables a deep swab or deep tissue to be taken for microscopy and culture

• Encourages healing by converting a chronic ulcer into an acute ulcer.

The debridement procedure

' Remove all callus surrounding the ulcer with a sterile scalpel

• When debriding the ulcer bed, work from the middle outwards: this carries debris and bacteria away from the ulcer bed

• Cut away all slough and non-viable tissue. It is helpful to grip the material that is to be cut away with a pair of forceps and to apply gentle traction so that the material to be cut is under tension. It is difficult to remove macerated callus or slough evenly and precisely, unless tension is applied (Fig. 4.1 la-d)

• The forceps are additionally useful as one arm can

Macerated Callus

Fig. 4.11 (a) Neuropathic ulcer surrounded by callus. Callus is grasped with forceps and cut with a scalpel, (b) Neuropathic ulcer after debridement, (c) Further neuropathic ulcer. Gentle tension is applied with the forceps to keep callus taut while it is being cut. (d) Neuropathic ulcer has been debrided down to healthy bleeding tissue.

Fig. 4.11 (a) Neuropathic ulcer surrounded by callus. Callus is grasped with forceps and cut with a scalpel, (b) Neuropathic ulcer after debridement, (c) Further neuropathic ulcer. Gentle tension is applied with the forceps to keep callus taut while it is being cut. (d) Neuropathic ulcer has been debrided down to healthy bleeding tissue.

be used as a probe to explore the dimensions of the ulcer

• Probe ulcer. If the probe reaches bone this is suggestive of osteomyelitis and the foot should be regarded as a stage 4 foot

• Clean ulcer with sterile normal saline

• Take deep swab/tissue samples (see Chapter 5 for details) and send for culture without delay

• Apply sterile dressing held in place with light bandage, which should not be wrapped too tightly or encircle the toe

• Review at regular intervals (ideally weekly) and repeat the procedure

• Always ensure the patient is reminded that if problems develop he should return to the clinic immediately.

Control of bleeding

Neuropathic feet can bleed with considerable exuberance. Have gauze swabs and calcium alginate to hand. Most bleeding will stop with pressure. Apply pressure over a swab damped with saline as when the swab is removed it will be less likely to dislodge the clot if it is damp. When debriding around an ulcer apply digital pressure locally to a bleeding point while still continuing to debride with the other hand, or apply a damp swab under pressure from bandage or tape to free both the operator's hands for further debridement.

When patients go home after bleeding is staunched, they can be given extra gauze and plaster to apply on top of the clinic dressing if bleeding strikes through.

If patients are prone to bleeding after debridement they should rest and elevate the foot at home for the next 24 h.

Before debriding the neuropathic foot, ask the patient whether he is on warfarin or heparin or has any bleeding disorder, in which case debridement should be cautious.

Diabetes Sustenance

Diabetes Sustenance

Get All The Support And Guidance You Need To Be A Success At Dealing With Diabetes The Healthy Way. This Book Is One Of The Most Valuable Resources In The World When It Comes To Learning How Nutritional Supplements Can Control Sugar Levels.

Get My Free Ebook


Responses

  • Retu
    Is it good debride all the callus overlying neuropathic ulcer in foot?
    4 years ago
  • belladonna goodbody
    Can osteomylitis be debreaded?
    3 years ago

Post a comment