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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.
Cases that are seen early often can be treated by closed reduction. It is believed that the injury in the case presented could have been treated by closed reduction if it had been recognized at the time of occurrence. This would have decreased the patient's long postoperative course. Hardcastle et al found that the postoperative results with the partial incongruity type Lisfranc dislocation were fair. Post-traumatic degenerative joint changes in the midfoot may occur and the patient should receive orthotic therapy.
In 1977, Davidson et al wrote an article entitled "Heel Neuroma." Since that time there has been a strong debate on whether the heel neuroma actually exists. The authors present a study of 14 patients presenting with recalcitrant heel pain. Each patient underwent surgical excision of a plantar heel mass. Two patients had bilateral procedures. Preoperative findings are compared with postoperative results. All of the patients experienced at least 75% relief, and the overall satisfaction rate was 79%.
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.
