Red case

A 38 year old man

with type 1 diabetes diagnosed at the age of 12 with HbA1c values higher than 8.5% most of the time

presents to a General Practitioner (GP) with a 48hr history of pain in the left foot after developing a rub from wearing new shoes about a week ago.

  • To provide an interactive case scenario that takes a clinician through a case example of a severe complicated DFU
  • To reinforce the need for holistic assessment of the patient
  • To reinforce the need for incorporating the principles of standard of care in the management of DFU
  • To reinforce the need for early referral to the specialist foot service team or to the Multidisciplinary Foot Team
2. Patients History

What factors from patient history would make you concerned?

The rapid decline over 48hrs? Yes /No

Correct answer :

Yes: The rapid evolution gives an indication that the ulcer is likely to deteriorate very quickly

Pain in the foot despite possibility of having neuropathy in the foot? Yes / No

Correct answer :

Yes: Having such level of pain in a patient with neuropathy partly indicates that the infection or wound is going into deep tissues

Developing such an ulceration after wearing new shoes implies the possibility of peripheral neuropathy. True / False

Correct answer :

True: The patient is likely to have neuropathy as he would not or did not feel the initial rubbing of the new shoes

The young age of the patient is reassuring because it makes him at a lower risk of diabetic foot complications. True / False

Correct answer :

False: the young age does not decrease the risk of complications. On the contrary, he may be at high risk of complications due to the long duration of type 1 diabetes and the need to be more active and mobile

3. Clinical Examinations

What factors from patient examination would make you concerned?

The rapidly spreading area of erythema or redness and areas of necrosis. Yes /No

Correct answer :

Yes: This gives an indication of significant infection and signs of tissue death.

Ability to touch/probe underlying bone with a metal object through the wound. Yes / No

Correct answer :

Yes: This indicates a positive ā€œprobe to boneā€ test hence the infection has spread to the bone and the patient is at high risk of an amputation.

(have a link to video on probe to bone test)

The ability to palpate all foot pulses rules out significant ischaemia in the foot. True / False

Correct answer :

False: The presence of necrosis or tissue death in such case should override the results of palpable foot pulses as they can also be falsely positive.

The presence of a previous amputation on the index or on the contralateral foot is an indication that the patient could be at risk of another severe complicated DFU. True / False

Correct answer :

True: It is always important to examine both feet, as having a previous amputations would imply that patient is at high risk of a further amputation.

4. Holistic approach

What factors from patient history would make you concerned?

Having systematically high HbA1c values Yes /No

Correct answer :

Yes: Having systematically high HbA1c values can be an indicator of non ā€“ acceptance and denial

Having a history of macro-albuminuria and an eGFR of 45 ml/min Yes / No

Correct answer :

Yes: the outcome of DFU is worse in cases with diabetes related kidney disease

Having a history of smoking for 8 years Yes / No

Correct answer :

Yes: Despite his young age, being a smoker together with high LDL and poor diabetes control can contribute to early vascular disease

Having a previous history of psycho-social problems Yes/No

Correct answer :

Yes: In this situationĀ  underlying depression is often overlooked. A holistic approach is needed in such patients as previous history of psycho-social problems can impact on follow up care and patientā€™s compliance.

5. Investigations

What investigations would you undertake during the patientā€™s visit?

Having a normal blood pressure, normal body temperature and heart rate is reassuring. True / False

Correct answer :

False: Patients with significant neuropathy may not always mount a systemic response to sepsis as it would be expected by the IDSA criteria. (have a link to IDSA criteria)

Raised blood sugar levels could be a sign of systemic stress or infection. True / False

Correct answer :

True: Body temperature may not be increased and raised blood sugars may be the only sign of evolving systemic sepsis.

It is appropriate to await blood test results for markers of infection before initiating a treatment plan in this case. True / False

Correct answer :

False: Such a rapidly deteriorating DFU needs to be escalated or actioned upon urgently without delay, or awaiting blood test results.

An x-ray is needed in this case to check for osteomyelitis before starting treatment or referring to a specialist foot team. True / False

Correct answer :

False: Although an x-ray could be useful it should not delay the initiation of treatment or the urgentĀ  referral to a specialist foot team.

Tissue samples for microbiology must be undertaken in this case and await results before initiating treatment plan. True / False

Correct answer :

False: Although a tissue sample is needed and would be useful, it should not delay the initiation of treatment in such rapidly progressing DFU.

6. Clinical Impression & Management Plan

What is the overall impression and how the case should be managed.

This case or DFU needs an immediate referral to a specialist foot service team within the same day. True / False

Correct answer :

True: This patient needs to be seen immediately in a hospital setting where he can have same day investigations with same day results and aggressive treatment.Ā  ( <24 Hours!)

The patient should be encouraged not to weight bear on the ulcerated foot. True / False

Correct answer :

True: the presence of osteomyelitis in the foot also means a risk of fracture to soft inflamed bones and subsequent Charcot deformity.

As a reviewing clinician one must ensure that the patient is seen on the same day by a specialist foot team or an accident and emergency department to initiate rapid treatment. True / False

Correct answer :

True: one needs to stress on the referral the need for urgent treatment of infection, foot x-ray and review of vascular supply to the foot.

Health care providers need to change their attitude to consider a RED DFU case as important as an acute myocardial infarction or Strokeā€¦.

7. Diagnosis and wound classification

What is your final diagnosis and try to classify this DFU according to SINBAD classification

a neuropathic ulcer ? an infected neuropathic ulcer? an infected neuro-ischaemic ulcer?

Correct answer :

This DFU is an infected neuro-ischaemic ulcer

  • Severe complicated DFU
According to SINBAD Score this DFU has the following score: ā€¦/6 ?

Correct answer :

According to Sinbad score, this DFU has a score 5/6.

8.1.a Case Outcome

Urgent surgical draining and debridement of dead and infected tissue.

It is important to have the infection and dead tissue removed surgically and urgently hence the need for urgent referral in such a case.


8.1.b Case Outcome

Initial foot X-ray

Osteomyelitis of the 5th toe and 5th metatarsal. The initial debridement concerns soft and bone tissue.


8.2.c Case Outcome

After the initial surgical debridement of infection one needs to address the ischaemia.


8.2.d Case Outcome

Urgent treatment of ischaemia

The patient presented with a chronic occlusion of the anterior tibial artery (ATA) and posterior tibial artery (PTA).Ā  The peroneal artery was the only artery feeding the plantar arch.


After Angioplasty: TheĀ  anterior tibial artery occlusion was recanalizated with long balloons (2x120 and 3x120): Pedal pulse was present again.

8.3.a Case Outcome

Months 1 and 2: Close follow up, use of negative pressure wound therapy and off-loading.



8.3.b Case Outcome

Months 3 to 4: After 4th toe arthroplasty was performed (conservative surgery), wound closure was achieved, and customised orthotic treatmentĀ  was initiated



8.4. Case Outcome


  • A biomechanical study for customised ortothic footwear could be helpful for secondary prevention.
  • Daily foot inspection
  • Regular follow up with a Specialist Foot care service (monthly)



9. Key Learning Points

1.Such case of DFU needs a rapid and fast-track referral to a specialist hospital with a specialist foot care team.

2.Firstly, it is important to treat the severe infection as early as possible and secondly to Ā address the ischaemia. Stop the infection: ā€œTime is tissueā€

3.A high grade of ischaemia can be present even in young patients.

4.It is important to have a high index of suspicion of ischaemia due to absence of clinical signs (including absence of rest pain in severe cases according to high prevalence of neuropathy)

5.Speed up the referral pathways to specialist centres if underlying necrotising infections are suspected