What is the management of a foot cut in a patient with diabetes mellitus (DM)?

Management of Foot Cut in Diabetes

A diabetic foot cut requires immediate systematic assessment and intervention with wound cleansing, sharp debridement of all necrotic tissue and callus, empiric oral antibiotics targeting S. aureus and streptococci, pressure offloading, and frequent monitoring—even if the wound appears superficial or uninfected. 1

Initial Assessment and Wound Evaluation

Assess the wound depth, vascular status, and infection severity immediately upon presentation:

• Determine wound depth: Probe the wound with a sterile metal probe to assess if bone is palpable, which suggests osteomyelitis 1
• Measure vascular perfusion: Obtain ankle-brachial index (ABI) and ankle systolic pressure immediately; if ankle pressure <50 mmHg or ABI <0.5, arrange urgent vascular imaging and consider revascularization 2, 3
• If available, measure toe pressure: Values <30 mmHg or TcPO2 <25 mmHg warrant revascularization consideration 2
• Classify infection severity: Even without systemic signs, diabetic foot wounds should be treated as infected due to the high risk of progression 1, 4

Immediate Wound Management

Perform aggressive local wound care at the first visit:

• Sharp debridement with scalpel: Remove all necrotic tissue, surrounding callus, and any foreign material; repeat as frequently as needed (often weekly or more) 1, 3
• Cleanse the wound thoroughly before debridement to optimize pathogen identification 1, 5
• Obtain wound cultures: Take specimens from the debrided wound base (not swabs) before starting antibiotics to guide therapy adjustment 4
• Avoid footbaths: Do not soak the foot as this induces skin maceration 1

Antibiotic Therapy

Start empiric oral antibiotics immediately, even for apparently superficial cuts:

• For mild/superficial infections: Initiate oral antibiotics targeting S. aureus and streptococci (cephalexin, flucloxacillin, or clindamycin) 1, 2
• Duration: Continue for 1-2 weeks for mild infections, extending to 2-4 weeks if response is incomplete 4
• For deep or limb-threatening infections: Urgently evaluate for surgical intervention and initiate empiric parenteral broad-spectrum antibiotics covering gram-positive, gram-negative, and anaerobic bacteria 1, 3
• Adjust antibiotics based on culture results and clinical response 1, 4

Pressure Offloading

Implement immediate pressure relief to prevent ongoing trauma:

• For plantar cuts: Use a non-removable knee-high offloading device (total contact cast or removable walker rendered irremovable) as first-line treatment 1, 3
• For non-plantar cuts: Consider shoe modifications, temporary footwear, toe-spacers, or orthoses 1, 2
• Instruct the patient: Limit standing and walking; use crutches if necessary 1
• During bed rest: Ensure heel protection to prevent contralateral foot ulceration 1

Local Wound Dressing Selection

Choose dressings based on exudate level and wound characteristics:

• Inspect the wound frequently (at least weekly initially) 1
• Select dressings to control excess exudation and maintain a moist environment: Use alginates or foams for wounds with purulent exudate 2, 3
• Avoid antimicrobial dressings: Silver-containing dressings, honey, and other antimicrobial agents are not well-supported for routine use 1, 3
• Consider negative pressure therapy for post-operative wounds if surgical intervention was required 1

Surgical Intervention Criteria

Urgently consult surgery if any of the following are present:

• Deep abscess or extensive purulent collection 1, 4
• Crepitus or necrotizing fasciitis 4
• Substantial necrosis or gangrene 4
• Extensive bone or joint involvement 4
• Infection advancing despite optimal medical therapy 5

Metabolic and Cardiovascular Management

Address systemic factors that impair wound healing:

• Optimize glycemic control to support healing and delay neuropathy progression 3
• Cardiovascular risk reduction: Emphasize smoking cessation, control hypertension and dyslipidemia, and initiate antiplatelet therapy (aspirin or clopidogrel) 1, 3

Patient Education and Monitoring

Provide specific instructions at the initial visit:

• Teach recognition of infection signs: Fever, increased wound drainage, worsening hyperglycemia, or changes in wound appearance 1
• Instruct on self-care: Proper wound inspection technique and when to seek immediate care 1
• Schedule close follow-up: Reassess within 48-72 hours initially, then weekly until healing trajectory is established 4

Critical Pitfalls to Avoid

Common errors that lead to poor outcomes:

• Do not wait for obvious infection signs before starting antibiotics—diabetic neuropathy masks pain and inflammation 4, 5
• Do not use the same footwear that caused the injury once healed 1
• Do not rely on wound swabs for culture—obtain tissue specimens from the debrided base 4
• Do not delay vascular assessment—ischemia is present in up to 50% of diabetic foot wounds and prevents healing 1, 6

Adjunctive Therapies for Non-Healing Wounds

If the wound shows insufficient healing after 2-6 weeks of optimal care:

• Consider hyperbaric oxygen therapy to hasten healing in poorly healing wounds 1, 2, 3
• Evaluate for revascularization regardless of initial vascular studies if no healing progress 1

Long-Term Prevention

Once healed, enroll the patient in an integrated foot-care program:

• Life-long observation with regular foot examinations 1
• Professional foot treatment and appropriate therapeutic footwear 1, 6
• Ongoing education for the patient and family 1