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Diabetic foot ulcer with limb ischaemia — MSRA MCQ

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HardAnkle and FootDiabetic foot ulcer with limb ischaemiaMSRA

A 71-year-old man with type 2 diabetes, CKD G3b, coronary artery disease and a 45-pack-year smoking history presents with a 3-week history of increasing pain in his left forefoot. The pain wakes him at night, is worse when the leg is elevated in bed and improves when he hangs the foot over the side of the bed. He has a 6 mm ulcer on the pulp of the left hallux that has not healed for 2 weeks. He is afebrile and systemically well. The ulcer has a pale base with no purulent discharge, surrounding erythema or malodour. The left foot is cool and pale compared with the right; dorsalis pedis and posterior tibial pulses are not palpable. Capillary refill at the hallux is 5 seconds. An ankle brachial pressure index measured in the practice is 1.08. What is the most appropriate management today?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: A — Refer immediately to acute services and inform the multidisciplinary foot care service

Explanation lettering: B = shown as A · D = shown as B · A = shown as C · E = shown as D · C = shown as E

This man has limb-threatening diabetic foot disease: an ulcer with clinical limb ischaemia. The discriminating features are ischaemic rest pain (worse on elevation and relieved by dependency), delayed capillary refill, a cool pale foot and absent pedal pulses. His normal ankle brachial pressure index does not safely exclude peripheral arterial disease because diabetes can cause arterial calcification and falsely normal or elevated readings. NICE recommends immediate referral to acute services, with notification of the multidisciplinary foot care service, for diabetic foot ulceration with limb ischaemia. This is required even though he is afebrile and the ulcer has no clinical features of infection. A is insufficiently urgent for ulceration with threatened limb perfusion; outpatient vascular investigation may follow acute assessment but must not delay it. C would be appropriate only if there were clinical diabetic foot infection; antibiotics do not address ischaemia and are not indicated here. D is inappropriate because a normal ABPI cannot exclude PAD in diabetes and repeat testing would delay definitive assessment. E is the pathway for other active diabetic foot problems, but ulceration with limb ischaemia requires immediate acute referral rather than routine triage within 1 working day.

Reference: NICE NG19: Diabetic foot problems: prevention and management — Recommendations (Updated 2019) — https://www.nice.org.uk/guidance/ng19/chapter/Recommendations NICE CG147: Peripheral arterial disease: diagnosis and management — Recommendations (Updated 2020) — https://www.nice.org.uk/guidance/cg147/chapter/recommendations NICE QS52: Peripheral arterial disease — Quality statement 1 (2014) — https://www.nice.org.uk/guidance/qs52/chapter/quality-statement-1-identification-and-assessment-of-peripheral-arterial-disease