MEDICAL SKILLS LABORATORY

FAKULTAS KEDOKTERAN UNIVERSITAS KRISTEN DUTA WACANA

DIABETIC FOOT ULCER

MANAGEMENT
dr. Yacobus Christian Prasetyo

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 LEARNING OBJECTIVES

1. Students can identify diabetic foot ulcer etiology, pathophysiology as

complication of DM.

2. Students can assess diabetic foot ulcer.

3. Students can demonstrate the management of diabetic foot ulcer.

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OUTLINE

ETIOLOGY,
PATHOPHYSIOLOG ASSESSING DFU
Y

DFU MANAGEMENT

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DFU ETIOLOGY &

PATHOPHYSIOLOGY
The underlying cause(s) of DFUs will have a significant bearing on the clinical
management and must be determined before a care plan is put into place
 Peripheral
Neuropathy

Diabetic
Foot
Ulcer
Peripheral
Both Arterial
Disease

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 Peripheral
Neuropathy

Sensory Motor Autonomic

Neuropathy Neuropathy Neuropathy

Loss of protective sensation is a major component of nearly all DFUs. It is

associated with a seven–fold increase in risk of ulceration.
Patients with a loss of sensation will have decreased awareness of pain and
other symptoms of ulceration and infection.

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 People with diabetes are twice as likely to have PAD as those without
diabetes. It is also a key risk factor for lower extremity amputation.

Decreased
PAD Ulcer
Perfusion

It is important to remember that even in the absence of a poor arterial

supply, microangiopathy contributes to poor ulcer healing in
neuroischaemic DFUs.

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ASSESSING DFU
Patients with a DFU need to be assessed holistically and intrinsic and
extrinsic factors considered.
DFU ASSESSMENT
As General Practitioner: knowing when and how to refer
a DFU patient to multidisciplinary foot care team
Assessment of DFU:
• History: risk factor, comorbidity, DM status, medication
• Visual exam
• Neuropathy assessment
• Vascular assessment
• Identification of Infection

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• Assessment of deformity
DOCUMENTATION
• Important tool for assessment of ulcer repairing rate. 
with informed consent from patient.
• At the beginning of every wound care session.

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PX VISUAL
• Predominant neuropathy, ischemic, or
neuroischemic? Is there deformity?
• Depth, size, location of ulcer. Base of
wound: black, yellow, pink? Is bone
seen?
• Infected? Are there systemic signs?
• Smelly wound? Exudate present?
Amount of exudates, color,
consistention, purulent? Is there pain?
• Side of the ulcer: callus, maceration,
erythema, edema, undermining?

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 PX NEUROPATI: MONOFILAMENT 10G

Positive: Patient cannot feel the

monofilament even with enough
pressure to bend it.

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PX NEUROPATI: 128HZ TUNING FORK

Vibrate the tuning fork, place it

at the patient’s foot.
Move up if patient unable to feel
the vibration.

Positive: Patient unable feel the

vibration of tuning fork.

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PX VASCULAR

Palpate the foot arteries: a.

femoralis, a. popliteal, a.
tibialis posterior, a. dorsalis
pedis.

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PX VASCULAR: ANKLE
BRACHIAL INDEX
ABI DIAGNOSIS CRITERIA
VALUE CLINICAL INTERPRETATION
1 – 1,4 Normal
0,91 – 0,99 Borderline
<0,9 PAD
0,5 – 0,9 PAD – Klaudikasio intermiten
0,3 - 0,5 PAD berat – resting pain
<0,3 Critical Ischemia –
ulcer/gangrene
>1,4 Noncompressible  periksa

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toe-brachial index
PX VASCULAR: DOPPLER USG
Using waveform from
Doppler USG.

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IDENTIFICATION
OF INFECTION
Culture is needed if
infection is
suspected.

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ASSESSING DEFORMITY
• A high-arch foot
• Clawed lesser toes
• Visible muscle wasting in the plantar arch
and on the dorsum between the metatarsal
shafts (a ‘hollowed-out’ appearance)
• Gait changes, such as the foot ‘slapping’ on
the ground
• Hallux valgus, hallux rigidus and fatty pad
depletion.

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DFU MANAGEMENT
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DFU
MANAGEMENT
• Treat underlying disease
• Adequate blood supply
• Wound management,
• Pressure offloading.

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1. TREATING UNDERLYING DISEASE
• Treating severe ischemia
• Optimal diabetic control
• Adressing physical cause of the trauma

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2. ADEQUATE BLOOD SUPPLY
• Surgical revascularization 
thrombectomy.

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3. LOCAL WOUND CARE
• Wound care for DFU should be on:
radical and repeated debridement,
frequent inspection and bacterial control
and careful moisture balance to prevent
maceration.
• TIME  Tissue management; Infection
control; Moisture balance; Epithelial
Edge advancement.

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4. PRESSURE OFFLOADING
• To distribute pressure evenly
• Inadequate offloading leads to
tissue damage and ulceration

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1. DFU can be either neuropathic, ischemic, or neuro-ischemic.

2. Holistic assessment of DFU: history, visual assessment,
neuropathy & vascular assessment, identification of infection
and deformity.
3. DFU management: Treating underlying disease, ensuring
adequate blood supply, wound management, and pressure
offloading.

DFU MANAGEMENT
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References
• International Best Practice Guidelines: Wound
Management in Diabetic Foot Ulcers. Wounds
International, 2013. Available from:
www.woundsinternational.com
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