■ Neuropathic Ulcer Over Prominent First Metatarsal Head
■ Neuropathic Ulcer over Prominent Metatarsal Heads
■ Neuropathic Ulcer over a Collapsed Midfoot
■ Neuropathic Ulcer Under Fourth Metatarsal Head
■ Neuropathic Ulcers Under Prominent Metatarsal Heads
■ Ulcers over a Charcot Foot
■ A Neuropathic Ulcer Under the Heel
■ Burns on Toes and Forefoot
■ Chronic Neuropathic Ulcer Complicated by Osteomyelitis
NEUROPATHIC ULCER OVER PROMINENT FIRST METATARSAL HEAD
A 54-year-old male patient with type 2 diabetes diagnosed at the age of 45 years was referred to the outpatient diabetic foot clinic because he had developed an ulcer on the plantar area of his left foot. He was treated with antidiabetic tablets and diabetes control was good (HBA1c: 7.1%). On examination he had a full thickness ulcer on the head of the first metatarsal in an area where there was gross callus formation (Figure 5.1). No signs of infection were observed. He had findings of diabetic neuropathy (no sensation of pain, light touch, temperature or vibration). Vibration perception threshold was 45 V on the right and >50 V on the left foot. His peripheral pulses were palpable and the ankle brachial pressure index was 1.2 bilaterally.
The patient did not have a previous history of problems with his feet. He denied any pain or trauma. He was aware of the presence of the ulcer, after he had seen discharge on his socks and the insole of his shoes. Debridement of the ulcer was carried out and the patient was advised to rest his feet; therapeutic footwear was also prescribed (Figure 5.2). This patient attended the diabetic foot clinic on a weekly basis and he changed the dressings every day. The ulcer healed completely in 10 weeks.
This is a typical neuropathic ulcer. Such ulcers are painless — unless they become infected—and develop in patients with neuropathy under areas of high-pressure loading. A callus forms at points of high repetitive pressure on the sole of the foot
and is a powerful predictor of ulceration. Such areas are the metatarsal heads and the plantar aspect of the great toe. Callus formation on the heel is not very common. In addition, calluses can develop over areas of bony prominences at other sites in the case of foot deformities (claw and hammer toes, toe overriding, neuro-osteoarthropathy). Even though the etiology of callus formation has not been determined, the fact that a callus acts as a foreign body in the shoe and contributes to high plantar pressure is well known. it is therefore recommended that callus formation should be prevented and when a callus is present, it should be removed regularly. Appropriate footwear is thought to prevent callus formation and the efficacy of this measure will be reflected by the proportion of patients wearing the correct footwear who develop ulcers. Hemorrhage into a callus is known as a 'pre-ulcer' and it should be treated as an ulcer.
Keywords: Neuropathic foot ulcer
A 53-year-old female patient who had had type 2 diabetes since the age of 41 years and was being treated with insulin, was referred to the outpatient foot clinic because of a chronic foot ulcer. she had background retinopathy, cataract, hypertension and ischemic heart disease. The patient complained of numbness and a sensation of pins and needles in her feet, which worsened during the night.
on examination she was found to have a full thickness ulcer under her second and third prominent metatarsal heads and claw toes (Figure 5.3). The patient had severe peripheral neuropathy (no sensation of light
touch, pin prick, temperature, 5.07 monofilament, absence of Achilles tendon reflexes; and a vibration perception threshold over 50 V). Peripheral pulses were palpable and the ankle brachial pressure index was 1.1 bilaterally.
The patient reported having a callus—probably due to high peak plantar pressures at the site of the callus — for the past 2 years, which she treated with pumice stone. Six months before her first visit, she noticed that the callus was harder and its base had become purple; when she decided to remove it using a blade, an ulcer developed, which she then treated with local antiseptics.
Debridement of the ulcer was carried out on a weekly basis.
Healthy granulating tissue was present at the base of this clean ulcer, together with mild callus formation at the border. The patient was advised to take prolonged bed rest and the ulcer healed completely in 6 weeks. Appropriate preventive footwear and orthotic insoles were prescribed in order to prevent the formation of a new ulcer.
This patient erroneously thought that pain in her feet was proof of a healthy peripheral nerve system. The combination of painful neuropathic symptoms and at the same time, complete absence of sensation
(a 'painful-painless foot') is a quite common feature of neuropathic diabetes.
Keywords: Neuropathic ulcer; granulating tissue
A typical neuropathic ulcer under a bony prominence in a patient with midfoot collapse due to neuro-osteoarthropathy is shown in Figure 5.4. Callus formation is present at the margins of the ulcer, while
Was this article helpful?