Educational tool quiz - Answers
Question 1
Patient is referred to your clinic with an infected ulcer and on clinical examination you find that the wound probes to bone. On performing an ankle brachial pressure index (ABPI) assessment in the same leg you obtain a reading of 0.49. What Texas wound classification grade would you assign?
Answer
(e) D3
The Texas classification is a useful tool to communicate the state of the wound and can also be used to guide wound management. In this case your patient has been identified as having lower leg ischaemia and the wound probes to bone with clinical signs of infection.
Question 2
What would be your initial treatment plan for the patient in question 1?
Answer
(c) Refer to vascular surgeon urgently, commence on antibiotics and arrange x-ray
The primary factor is the poor arterial supply, reflected by the low ABPI reading. It is likely that this will compromise the ability of the ulcer to heal and will reduce the delivery of oral antibiotics to the affected area. The possibility of osteomyelitis should be investigated with radiological imaging because this will affect choice of antibiotics and influence a decision about possible surgical intervention.
Question 3
Mr Jones has been attending the diabetic foot clinic for two months with a non-healing ulcer on the left 5th toe. He has good peripheral pulses but has been non-compliant with footwear to take the pressure off the wound. Today the wound presents with at least 2 cms of erythema and increased exudate. He informs you he can feel the toe now, which is unusual as he usually cannot due to neuropathy. He has also noticed his sock now becoming stained even with the dressing on. What would be your initial management?
Answer
(b) Commence on broad spectrum antibiotic, take a microbiology swab and see in one week
Both the patient’s history and the examination findings indicate infection. New-onset pain in a foot affected by neuropathy is a cause for concern, as well as the increased ulcer exudate staining his sock. The patient has had an ulcer for two months indicating a chronic wound, Clinical examination demonstrated erythema which again is likely to be due to infection.
The wound should be classified as a chronic ulcer, because it has been present for more than 6 weeks, and so a polymicrobial infection is likely, requiring a broad spectrum antibiotic.
It is important to review the ulcer in one week to check for improvement; if no improvement or deterioration has occurred, the culture results from the swab should be used to guide further antibiotic therapy.
Question 4
A patient attends your clinic complaining of a new ulcer on the side of his left foot, which he explains began at the weekend. On taking a full history he tells you the foot became hot and swollen about two weeks ago and the ulcer formed after he tried to get his favourite shoes on. Examining the left foot, it is hotter than the right foot with increased oedema. Your patient is unable to feel a 10g monofilament and has reduced vibration sense, indicating neuropathy of both feet. Following limb elevation the redness and swelling dissipates from around the ulcer. What is the likely cause of this presentation?
Answer
(c) Patient has acute Charcot neuroarthropathy
The answer is provided by careful history taking and clinical examination. Acute Charcot neuropathy should be suspected in a hot swollen foot exhibiting neuropathy. The ulcer is likely to be secondary to friction from the patient’s shoes in the presence of oedema. Dissipation of erythema and swelling with limb elevation supports a non-infected presentation. If infection were present, these signs would not be reduced by raising the limb.
Question 5
Mr Sharp has been referred to your clinic due to an infection of his right foot. He presents with cellulitis tracking from the inter-digital space of his right 4th and 5th toes. You take a detailed history which includes his physical activity levels, discovering that he participates in a lot of sports and tends to live in his trainers. On further questioning he informs you that he has a tendency to scratch between the toes due to a localised skin itch. On examination, there is maceration and skin peeling in the interdigital areas between these toes, matching to the areas of itch. What is your initial management?
Answer
(e) Commence flucloxacillin 500mgs qds and terbinafine 1% cream bd, review in one week and stress importance of good foot care
Patent describes a history of itching between his toes and is likely to be cross infecting his feet due to scratching these areas. He has poor footwear hygiene by wearing his trainers for long periods, increasing his susceptibility to fungal infections of the feet. The bacterial infection is secondary to him scratching these areas, compromising the skin barrier. Management includes treating the bacterial infection as well as the underlying fungal infection. Definitive diagnosis of fungal infection is by taking skin scrapings for microscopy and mycological culture. Management should include advice regarding foot care to reduce the risk of recurrence and proactive treatment with topical terbinafine should tinea pedis recur, to prevent secondary bacterial infection arising.
Question 6
Mrs Jones has been referred to your team having had a foot ulcer for 3 months with repeated infections requiring several courses of oral antibiotics. On examination she has a necrotic plaque over her left first metatarsophalangeal (MTP) joint which clinically appears to be infected. Mrs Jones is known to have peripheral neuropathy and her ABPI is 1.1 in this leg. What is your initial treatment plan?
Answer
(d) Commence on a broad spectrum antibiotic and perform sharp debridement
The patient has a history of repeated infections, which could be due to antibiotic resistance or re-infection of the superficial tissue from an inadequately-treated deeper infection. In this case good debridement should be carried out to see if a deeper underlying problem is present. Sharp debridement can be performed because the patient has an adequate arterial supply. A broad spectrum antibiotic is the first line treatment of choice because the ulcer has been present for more than 6 weeks.
Question 7
During Mrs Jones’ debridement, sharp fragmented loose bone is felt. What course of action would you take now?
Answer
(e) Commence bone-penetrating antibiotics and send for x-ray
The presence of fragmented bone is highly suspicious of osteomyelitis and therefore warrants commencement of bone-penetrating antibiotics in line with the local osteomyelitis pathway. Sending bone fragment samples for culture and sensitivity will guide subsequent antibiotic treatment. Plain x-rays are helpful to confirm the diagnosis and provide a baseline for sequential x-rays to monitor treatment of the infection.
