Understanding the factors associated with pedal ulceration in patients with diabetes mellitus will increase the successful management of the high-risk diabetic foot and decrease the occurrence of ulcerative events. The authors review the associative factors that have been shown to be involved with pedal ulceration.
While there have been several reports of upper and lower extremity amputations secondary to meningitis and purpura fulminans in the literature, the incidence is probably rare. Delmas et al studied five pediatric subjects with gangrene caused by meningococcemia, with four requiring amputation. Weiner reported that all 12 patients in his review received a lower extremity amputation, with several requiring upper extremity amputation. Joint contracture, while not as commonly discussed as amputation, is nonetheless an important and perhaps more common finding. Urbaniak et al indicated that of six patients reviewed, three developed significant joint contractures. With the exception of the gangrenous changes discussed, it was joint contracture that was the most limiting factor in progression to full activity and weightbearing in the authors' subject. Prompt, aggressive physical therapy is tantamount to effecting an acceptable long-term outcome.
Appropriate care of feet of patients with diabetes requires a clear, descriptive classification system that may be used to direct appropriate therapy and possibly predict outcome. Ideally, this system would be used by all participants in a multidisciplinary limb-salvage team. The authors report on a logical, treatment-oriented system that may improve communication, leading to a less complex, more predictable treatment course and, ultimately, an improved result.