Infection masked by irregular dressing changes

An 84-year-old man with type 2 diabetes of 12 years' duration, a previous above-knee amputation and a neuroischaemic foot (Fig. 5.22) developed a shallow ischaemic ulcer on his 2nd toe and a dressing was applied and changed at weekly intervals. Between dressing changes the ulcer deteriorated and became sloughy and deep with associated cellulitis, although the patient felt no pain. He was admitted to hospital for intravenous antibiotics.

Sloughy Area
Fig. 5.22 Cellulitis and sloughy ulcer on dorsum of 2nd toe.

Vascular intervention was not feasible. The ulcer took 13 months to heal.

Key points

• Patients who lack protective pain sensation should have regular and frequent wound inspections

• We avoid using dressings which cannot be lifted fre-quendy on patients without protective pain sensation

• Healing of previously infected lesions is very protracted in neuroischaemic patients.

Wound care of ulcers with diffuse spreading erythema, ulcers with extensive deep soft tissue infection and ulcers with extensive erythema and blue/purple/black discolouration of surrounding tissues

Diffuse spreading cellulitis should respond to intravenous antibiotics, but the patient needs daily review to detect evidence of spreading infection. An outline of the area of cellulitis may be drawn on the foot with a spirit-based pen so that extension of the cellulitic area can be detected quickly.

In extensive deep soft tissue infection and cellulitis with blue-black discolouration, the ulcer may be complicated by sloughy infected soft tissue. It is best for this tissue to be removed operatively.

The definite indications for urgent surgical intervention (as described above on p. 117) are:

• A large area of infected sloughy tissue

• Localized fluctuance and expression of pus

• Crepitus with gas in the soft tissues on X-ray

• Purplish discolouration of the skin, indicating subcutaneous necrosis.

We have repeated these indications here as we believe that they are so important. In these circumstances surgical debridement is always necessary in either neuropathic and neuroischaemic feet. However, if the foot is neuroischaemic, surgical debridement needs to be accompanied by an assessment of the arterial perfusion to the foot to evaluate the healing potential of surgical wounds. These patients will need timely vascular intervestigation.

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