What is the best treatment for a deep tissue injury (DTI) of the heel?

Management of Deep Tissue Injury (DTI) of the Heel

The best treatment for deep tissue injury (DTI) of the heel requires prompt offloading, appropriate wound care, and consideration of surgical intervention based on wound severity and vascular status. 1

Initial Assessment and Management

• Thoroughly assess the wound to determine depth, extent, and presence of infection, using a sterile blunt probe to measure depth and check for exposed bone 1
• Evaluate vascular status by checking pedal pulses; if pulses are diminished, consider vascular studies (ABI, TcPO2) to determine if revascularization is needed 1
• Assess for peripheral neuropathy using a 10-g monofilament test, as neuropathy affects wound healing and treatment approach 1

Primary Treatment Strategies

Offloading

• Implement immediate pressure relief using appropriate offloading devices 1
  • For heel DTIs, consider heel-relief shoes where the rearfoot part is missing from the footwear 1
  • Total contact casting or non-removable walkers may be used for severe cases to ensure compliance with offloading 1

Wound Care

• Debride necrotic, non-viable tissue while preserving viable tissue 1
• For heel DTIs specifically, it may be best to leave adherent eschar in place, especially on the heel, until it softens enough to be more easily removed, provided there is no underlying infection 1
• Apply appropriate wound dressings based on wound characteristics 1:
  • Continuously moistened saline gauze for dry or necrotic wounds
  • Hydrogels for dry/necrotic wounds to facilitate autolysis
  • Alginates for exudative wounds
  • Hydrocolloids for absorbing exudate and facilitating autolysis

Infection Management

• If infection is present, obtain tissue samples for culture prior to initiating antibiotic therapy 1
• Provide appropriate antibiotic therapy based on culture results 1
• For moderate to severe infections, consider early surgical intervention (within 24-48 hours) to remove infected and necrotic tissue 1

Advanced Treatment Options

Surgical Intervention

• Consider surgical consultation for:

  • Deep abscesses or compartment syndrome 1
  • Necrotizing soft tissue infections 1
  • Osteomyelitis with spreading soft tissue infection 1
  • Severe ischemia with infection 1

• Surgical options for severe heel DTIs may include 2, 3:

  • Debridement of necrotic tissue
  • Drainage of deep spaces of the heel
  • Partial or total calcanectomy for extensive bone involvement
  • Creation of heel flaps for reconstruction in selected cases

Vascular Assessment and Intervention

• If ischemia is present, urgent vascular specialist consultation is recommended 1
• Revascularization (endovascular or bypass) may be needed before definitive wound management in cases of severe ischemia 1
• For patients with diabetes, PAD, and infected foot ulcers, coordinate between surgical and vascular specialists to determine timing of drainage and revascularization 1

Adjunctive Therapies

• For wounds that fail to show 50% reduction after 4 weeks of appropriate management, consider advanced wound therapies 1:
  • Negative pressure wound therapy for large defects 4
  • Hyperbaric oxygen therapy may be considered for non-healing diabetic foot ulcers after revascularization 1
  • Split-thickness skin grafts for large skin defects 4

Special Considerations

• Heel DTIs in diabetic patients require a multidisciplinary approach involving wound care specialists, vascular surgeons, and infectious disease specialists 2
• Large and deep heel ulcers can be successfully managed without amputation in 89% of cases with appropriate multidisciplinary care 2
• Regional anesthesia with sedation rather than general anesthesia may be preferable for heel debridement procedures 5

Monitoring and Follow-up

• Regularly measure and document wound size, extent of surrounding cellulitis, and quality/quantity of drainage 1
• Reassess the wound weekly to evaluate healing progress and adjust treatment plan accordingly 1
• Once healed, implement a comprehensive prevention program to reduce recurrence risk 1