Ulcers (wounds) involving the feet and toes are most commonly seen in diabetic patients and are commonly called diabetic foot ulcers (DFUs). Similar wounds are also seen in older patients with peripheral arterial disease (PAD), end stage renal disease (ESRD) and other conditions.
These wounds generally fall into 3 categories, neuropathic, neuroishcemic and ischemic.
- Neuropathic wounds are caused a loss of sensation in the foot leading to repeated trauma and injury with eventual skin break down.
- Ischemic wounds are caused by the loss of blood flow to the foot.
- Neuroischemic wounds fall in the middle and are caused by both neuropathic and ischemic problems.
Whenever presented with a foot wound we need to determine whether or not there is an ischemic component to that wound. Clinical evaluation has shown to be limited this regard. Patients with palpable pulses still may have significant foot ischemia. Objective testing using skin perfusion pressures or toe brachial index (TBI) is required.
Too often patients with an ischemic component to their ulcer do not undergo physiologic evaluation to see if they would benefit from revascularization. In fact, many patients end up with an amputation as their first procedure. It is absolutely paramount that all patients with a non-ulcer be seen by an expert in evaluating patients for critical limb ischemia before there undergo an amputation.