Neuropathic ulcer with extensive sloughing of subcutaneous tissue

A 68-year-old man with type 2 diabetes of 15 years' duration presented with a swollen left foot which was brawny and cellulitic. There was a deep ulcer over the 4th metatarsal head discharging pus (Fig. 5.19a). It had started as a blister 4 weeks previously. Pulses were bounding. Tissue was sent for culture and he was admitted and treated intravenously with amoxicillin 500 mg tds, flucloxacillin 500 mg qds, metronidazole 500 mg tds and ceftazidime 1 g tds. He underwent operative surgical debridement on the same day (Fig. 5.19b). There was extensive subcutaneous sloughing of deep tissue down to bone in the forefoot. Culture of tissue from the diabetic foot clinic and tissue taken at surgery both grew Staphylococcus aureus, Proteus spp. and mixed anaerobes. The initial antibiotic regime was continued to eradicate the above organisms until the cellulitis had settled. He made a good recovery and the wound healed within 10 weeks (Fig. 5.19c).

Key points

• The patient presented with an extensive deep lesion which had simply started as a blister 4 weeks previously and had recently developed a rapidly extending infection

• The patient had been previously given flucloxacillin but the tissue grew Proteus and mixed anaerobes which would not have been sensitive to flucloxacillin

• This was a polymicrobial infection which needed combined antibiotic therapy

• There was extensive soft tissue destruction and the patient required urgent operative surgical debridement.

Ulcer with extensive erythema and with blue/purple/ black discolouration of surrounding tissues

Neuropathic feet and neuroischaemic feet. The antibiotic therapy and follow-up plan is the same as above but surgery should be considered urgently. If the blue or purple discolouration is noted and treated promptly then it may resolve and the skin return to a normal colour. However, if intervention is late the blue discolouration indicating compromised oxygen supply to the skin will lead to necrosis and the foot moves to stage 5.

It is important to explore the possibility of revascularization in the infected neuroischaemic foot. Improvement of perfusion will not only help to control infection, but also promote healing of wounds if operative debridement is necessary.

Neuroischemic Foot Ulcer

Fig. 5.19 (a) Deep ulcer with subcutaneous sloughing visible. tissue down to healthy bleeding tissue, (c) The wound is healed

(b) Extent of debridement necessary to remove all necrotic at 10 weeks.

Fig. 5.19 (a) Deep ulcer with subcutaneous sloughing visible. tissue down to healthy bleeding tissue, (c) The wound is healed

(b) Extent of debridement necessary to remove all necrotic at 10 weeks.

Diabetes 2

Diabetes 2

Diabetes is a disease that affects the way your body uses food. Normally, your body converts sugars, starches and other foods into a form of sugar called glucose. Your body uses glucose for fuel. The cells receive the glucose through the bloodstream. They then use insulin a hormone made by the pancreas to absorb the glucose, convert it into energy, and either use it or store it for later use. Learn more...

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Responses

  • jukka-pekk
    How does a subcutaneous ulcer heal?
    5 years ago
  • FALCO
    How to heal a foot ulcer?
    5 years ago
  • Maximilian
    What is a deep tissue ulcer?
    5 years ago
  • albano
    What is sloughing wounds?
    5 years ago

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