How to manage a worsening right foot fracture in a patient with poorly controlled diabetes and other comorbidities?

From the Guidelines

Managing a worsening right foot fracture in a patient with poorly controlled diabetes requires immediate multidisciplinary care, prioritizing blood glucose control, offloading, infection prevention, and pain management to minimize morbidity, mortality, and improve quality of life. The patient should be referred to an orthopedic surgeon and endocrinologist without delay. Blood glucose control must be optimized, aiming for fasting levels between 80-130 mg/dL and HbA1c below 7%, using appropriate adjustments to insulin or oral medications, as emphasized in the IWGDF/IDSA guidelines on the diagnosis and treatment of diabetes-related foot infections 1.

Key Considerations

• Offloading the affected foot is critical, typically with a total contact cast, removable cast walker, or custom orthotic device, to reduce pressure and promote healing.
• Infection prevention is essential, with regular wound assessments and prompt antibiotic therapy if infection develops, using empiric options such as amoxicillin-clavulanate or clindamycin for mild infections, as recommended by the Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections 1.
• Pain management should utilize acetaminophen as first-line, with cautious use of short-term opioids if necessary, to ensure the patient's comfort without compromising their recovery.
• Nutritional support with adequate protein intake and vitamin supplementation, particularly vitamin D, promotes healing and should be tailored to the patient's specific needs.

Monitoring and Follow-Up

• Regular imaging, such as X-rays every 2-4 weeks initially, helps monitor fracture healing and should be adjusted based on the patient's progress.
• The patient's blood glucose levels, wound status, and overall condition should be closely monitored to promptly address any complications or concerns, as highlighted in the guidelines 1.

Surgical Intervention

• If conservative measures fail, surgical intervention may be necessary, potentially including internal fixation or, in severe cases, partial foot amputation, to prevent further complications and improve the patient's quality of life. The decision for surgical intervention should be made in consultation with an orthopedic surgeon and other relevant specialists, taking into account the patient's overall health and the severity of the fracture.

From the Research

History of Present Illness (HPI)

The patient is a 47-year-old female with a history of poorly controlled diabetes, bipolar disorder, hyperlipidemia, and GERD. She presented to the ER with a right foot fracture on 5/27/25 and was instructed to wear a walking boot for 6 weeks. However, she has not been wearing the boot due to increased pain.

Chief Complaint

The patient reports severe right foot pain (10/10) radiating up to her knee for two weeks, described as throbbing and worse with activity. She denies numbness or tingling.

Injury Mechanism

The patient reports that the injury occurred at home when she got out of bed quickly. She also mentions that returning to work exacerbated the original injury, leading her to seek ER attention.

Management of Worsening Right Foot Fracture

• The patient's poorly controlled diabetes and other comorbidities, such as hyperlipidemia, need to be considered when managing her right foot fracture 2.
• A thorough evaluation of the foot and ankle is necessary to determine the cause of the worsening pain, using a mnemonic approach to assess the cutaneous, vascular, and neural systems 3.
• The patient's history of diabetes and potential for foot complications highlights the importance of preventive measures, such as educational programs for healthcare providers to identify at-risk patients 4.
• The use of paracetamol (acetaminophen) for pain management should be considered with caution, as it may be associated with an increased risk of fracture 5.
• The patient's non-adherence to the walking boot instruction may have contributed to the worsening of the fracture, and alternative management strategies should be explored to ensure proper healing and prevent further complications.
• Referral to a specialist, such as a podiatrist or orthopedist, may be necessary to provide a second opinion or therapeutic assistance in managing the patient's worsening right foot fracture 3.