Wound care of ulcers with local signs of infection and ulcers with surrounding erythema

Ulcers with local signs of infection and ulcers with associated cellulitis should have podiatric debridement as described below.

Podiatric debridement of neuropathic ulcers

' All callus surrounding the wound is removed by sharp debridement

• If the ulcer is subungual, overlying nail is cut back to expose the base of the ulcer

• Undermined areas detected by probing are cut out

• Sloughy or discoloured areas of the wound bed are sharp debrided down to healthy bleeding tissue. Local discolouration of the wound bed is often a marker for an underlying track or fluctuant area containing pus. Sometimes the track has not yet broken through to the surface and the only indication of its presence is that the tissue of the wound bed which overlies the track may be a different colour, often greyish or purple. The discoloured area should be debrided away using scalpel and forceps to explore the underlying area

• Where a wound sinus is present and is very small it may be enlarged with a scalpel in order to aid drainage and enable tissue to be taken. The sinus may appear as an obvious hole in the wound bed or as a tiny slit, which is easily overlooked

• Sometimes the edges of the slit are pouting, the ulcer is very wet, and on palpation, pus or serous fluid emerges from the sinus. Fluctuant areas are drained. If pus is present it is collected in a syringe or small sterile pot for culture

• The ulcer is cleaned with normal saline. Curettings or deep swab are taken from the base of the ulcer and sent to the laboratory for culture

• Extent of cellulitis is marked with a spirit-based fibre pen so that any extension can be noted next time the dressing is lifted

• A sterile, absorbent, easily lifted dressing held in place with a light tubular bandage is applied

• The patient is instructed not to walk but to rest and elevate the foot and use crutches or wheelchair

• The dressing is lifted every day for wound inspection and to check the extent of the cellulitis. Callus or slough which reforms is sharp debrided at frequent intervals (not longer than 1 week).

Podiatric debridement ofneuroischaemicfeet

Neuroischaemic feet with signs of local infection or local cellulitis are treated as above but with some important differences which are described below.

• Debridement is far less aggressive than for the neuropathic foot

• Accretions of slough in the wound bed are gently debrided with scalpel and forceps but great care is taken not to damage viable tissue

• If deep sinuses are located by probing, they should not be enlarged unless there is a very obviously fluctuant area associated with the sinus. In these circumstances the advantages of draining pus outweigh the danger of damaging ischaemic tissues

• Undermined edges are not removed

• If a halo of very thin dry callus develops around the ulcer it is very carefully debrided

• If the ulcer is subungual, overlying nail is very gendy pared away so that the ulcer can drain

• The patient is sent to the hospital immediately if the foot deteriorates.

Dressing regimes for ulcers with local signs of infection or surrounding erythema

Regular dressing changes are important for all infected diabetic foot ulcers. Exudate may cause maceration and irritation of the tissues surrounding the ulcer. At dressing change, infected ulcers and surrounding areas should be carefully cleansed with saline and dried before a fresh dressing is applied. Simple, non-adherent dressings which are easily lifted are best. Any dressing which might prevent the free flow of exudate from an infected foot, or clog up a discharging sinus, should be avoided. Dressings should always be changed before 'strike-through' occurs.

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