Ryan Fitzgerald, DPM PRESENT RI Associate Editor Washington Hospital Center Washington, DC

Case Presentation:
Diabetic with nephropathy requiring
hemodialysis treatment

HPI: The patient is a 62-year-old male who presents with a history of a large posterior leg wound for approximately the last month.  The patient is a diabetic with nephropathy who recently began to require hemodialysis treatment.  The patient was initially referred to a general surgeon who recommended below-knee amputation, and the patient subsequently sought out the high-risk diabetic foot clinic for a second opinion.

VS:  Tc:987, BP:132/84, RR: 18, HR: 82 BPM
PMH: Diabetes, Hypertension, ESRD on HD
MEDS:  Novolog 70/30, Atenolol, plavix, aspirin
ALL: Iodine
SOCIAL: Previous Tobacco history, 20 pack years (stopped 17 yrs. ago), social ETOH, denies illicit drug use.

PHYSICAL EXAM: the pedal pulses are palpable, and graded +1/4 at the dorsalis pedis and posterior tibial arteries to the left lower extremity.  There is a large partially circumferential wound along the posterior aspect of the patient’s leg measuring approximately 15.3cm x 8cm x 0.3cm (fig. 1).  The wound demonstrates a mixed fibro-granular base, with fibrinous exudate and there are additional superficial wounds noted around the anterior lateral aspect of the patient’s leg, measuring 4cm x 5 cm x 0.2cm (fig. 2).   At the inferior aspect of the large posterior wound, approximately 7cm of achilles tendon is noted to be exposed and mildly dissected (Fig. 3).  Protective sensation is grossly intact to distal extremity via 5.07 semmes-weinstein monofilament test and vibratory sensation is grossly intact.  There is no significant malodor noted, and there is no bone exposed.

Click on the images below for a full-screen view.

Figure 1: A large posterior wound which wraps circumferentially approximately 2/3rd of the around the distal lower leg.

 

Figure 2: In addition to the large posterior wound, the patient presents with several anterior leg satellite lesions that demonstrate a mixed fibro-granular base.

 

Figure 3: Approximately 6 cm of achilles tendon is noted in the inferior portion of the posterior wound; also visible are the satellite lesions along the anterior of the leg.

 

WHAT DO YOU THINK?

Considering the history, physical exam, and clinical images presented, how would you proceed with this case? Please Reply with your thoughts and perspectives–we'll share them in a future RI.