From the Guidelines
Management of a distal phalangeal fracture in a diabetic patient with a previous amputation requires prompt orthopedic consultation, strict blood glucose control, and appropriate immobilization with a custom-fitted splint. The patient's history of diabetes and previous amputation increases the risk of complications, including delayed healing and infection.
- Key considerations include:
- Strict blood glucose control, maintaining levels between 80-180 mg/dL, to optimize healing conditions 1
- Appropriate immobilization with a custom-fitted splint that accommodates the patient's altered anatomy from previous amputation
- Antibiotic prophylaxis, typically with amoxicillin-clavulanate 875/125 mg twice daily for 5-7 days or clindamycin 300 mg four times daily if penicillin-allergic, to prevent infection
- Pain management with acetaminophen (1000 mg every 6 hours) rather than NSAIDs, which can impair bone healing and affect kidney function
- Close monitoring for signs of infection, with follow-up appointments at 1,2, and 4 weeks post-injury
- Nutritional support with adequate protein intake (1.2-1.5 g/kg/day) and vitamin D supplementation (1000-2000 IU daily) to optimize healing conditions
- Physical therapy to begin as soon as clinically appropriate to maintain function and prevent stiffness in the remaining digits According to the International Working Group on the Diabetic Foot (IWGDF) guidelines, patients with diabetes and a history of foot ulceration or amputation are at higher risk for recurrent foot ulcers and require regular screening and preventive measures 1.
- The IWGDF guidelines recommend:
- Annual screening for signs or symptoms of peripheral neuropathy and peripheral artery disease
- Treatment of any pre-ulcerative signs on the foot, including removing callus, protecting blisters, and treating ingrown or thickened toenails
- Instructing patients to daily inspect their feet and the inside of their shoes, wash their feet, and use emollients to lubricate dry skin
- Prescribing therapeutic footwear that has a demonstrated plantar pressure-relieving effect during walking to prevent recurrent plantar foot ulcers.
From the Research
Management of Distal Phalangeal Fracture in a Diabetic Patient
The management of a distal phalangeal fracture in a diabetic patient with a previous amputation requires careful consideration of several factors, including the risk of infection, the potential for healing, and the need to minimize the risk of further complications.
- Infection Risk: The use of antibiotics in the management of open fractures of the distal phalanx is recommended, as it has been shown to reduce the infection rate from 30% to less than 3% 2.
- Healing Time: Studies have shown that diabetes mellitus does not significantly affect the healing time of foot and ankle fractures, provided that standard treatment is delivered in a timely manner 3.
- Treatment Approach: For patients with stable, minimally displaced injuries, conservative modalities such as prolonged immobilization and non-weight-bearing may be sufficient 4. However, for patients with unstable or displaced fracture-dislocations, open reduction and internal fixation, possibly combined with external fixation, may be recommended.
- Foot-Sparing Surgery: The importance of foot-sparing surgery in diabetic patients cannot be overstated, as it can help to minimize the risk of further complications and improve functional outcomes 5.
- Aggressive Management: Initial aggressive management of neuroarthropathic fracture-dislocations in diabetic patients can help to avoid or minimize the disastrous sequelae of a destructive neuroarthropathic process and can result in a biomechanically sound plantigrade, braceable, and shoeable lower extremity 4.
- Structured Clinical Assessment: A structured clinical and vascular assessment can help to inform clinical decision-making and determine the best course of treatment for each individual patient 6.