Special reports Case reports The ulcer at the base of the left second,


third and fourth toes, which included the exposed proximal phalanges [Fig 2], was not flat and it was necessary to prevent dead space developing between the ulcer base and any dressing material, as accumulated exudate here could have damaged the ulcer base, as well as the periwound area. Overall, this patient’s ulcer was causing


Figure 2. The proximal phalanges of the patient’s left second, third and fourth toes were exposed, demonstrating periwound maceration and contact dermatitis.


References


1. Woo K, Sibbald G, Fogh K, Glynn C, Krasner D, Leaper D, Osterbrink


J, Price P, Teot L. Assessment and management of persistent (chronic) and total wound pain. Int Wound J 2008; 5: 205–15.


2. Tanenberg R, Donofrio P. Neuropathic problems of the lower limbs in diabetic patients. In: Bowker JH,


Pfeifer MA, (eds). Levin and O’Neal’s the Diabetic Foot. 7th edn. 2008; Mosby Elsevier, Philadelphia: 33–74.


3. Wulf H, Baron R. The theory of pain. EWMA Position Document: pain at wound dressing changes. Medical Education Partnership, London; 2002; 8–11.


4. World Union of Wound Healing Societies. Principle of Best Practice: minimizing pain at wound dressing


procedures. 2008; Available at: www. wuwhs.og.


5. Tsuji Y, Terashi H, Kitano I, Tahara S, Sugiyama D. Importance of skin perfusion pressure in treatment of


critical limb ischemia. Wounds 2008; 20: 95–100.


6. Phillips DM. JCAHO Pain management standards are unveiled. JAMA 2000; 284: 4–5.


7. Frasco PE, Sprung J, Trentman TL. The impact of the joint commission for accreditation of healthcare organizations pain initiative on


perioperative opiate consumption and recovery room length of stay. Anesth Analg 2005; 100: 162–68.


8. Sussman G. Management of the


wound environment with dressings and topical agents. In: Sussman C,


Bates-Jensen BM, (eds). Wound Care. 3rd edn. 2007; Lippincott Williams & Wilkins, Philadelphia: 250–67.


patient onto the authors’ hospital. The endovascular treatment had been


performed using a catheter to relieve stenosis of the superficial femoral artery. The blood vessels below the patient’s knee demonstrated peripheral vascular disorder caused by the Buerger’s disease. Furthermore, stenosis of superficial femoral artery was caused by diabetic vascular disorder. Debridement of the left second, third and


fourth toes was performed at the previous hospital, but the patient was told that transtibial amputation would be required in order to achieve wound closure. He visited the author’s clinic because he wanted to preserve his heel. At the first visit to the authors’ clinic [Fig


2], the patient’s skin perfusion pressure (SPP) was low at 18mmHg at the dorsum of the foot, and 28mmHg at the sole. An SPP of more than 35mmHg is thought to be required for wound healing[5]


Figure 3. The wound contracted to the exposed proximal phalanges and exhibited epithelialisation.


wound-related pain and inhibiting healing and this needed to be treated. Therefore, a Hydrofiber® (Aquacel AG®


dressing incorporating silver ; ConvaTec) was applied to the


ulcer base and a steroid used on the rest of the foot. Compared with polyurethane foam or hydrocolloid dressings, the author’s clinical


. Cilostazol was


administered to treat the peripheral arterial disease and smoking cessation was also strictly enforced. The previous clinicians had used


physiological saline warmed to room temperature, rather than body temperature, to cleanse the wound and the skin had become hypersensitised to the discomfort caused by this. Moreover, the wounds were dressed with


silver sulfadiazine cream and gauze, which were not able to control the wound exudate, which subsequently caused maceration. Due to the maceration, the skin barrier function was damaged. Together, these elements resulted in contact dermatitis, another potential cause of hypersensitisation [Fig 2]. The associated inflammation was treated using topical steroids.


48 Wounds International Vol 3 | Issue 3 | ©Wounds International 2012


Figure 4. Debridement of exposed proximal phalanges and necrotic tissue of the first and fifth toes was performed.


Figure 5. Granulation tissue covering the bone at the amputation site.


Page 1  |  Page 2  |  Page 3  |  Page 4  |  Page 5  |  Page 6  |  Page 7  |  Page 8  |  Page 9  |  Page 10  |  Page 11  |  Page 12  |  Page 13  |  Page 14  |  Page 15  |  Page 16  |  Page 17  |  Page 18  |  Page 19  |  Page 20  |  Page 21  |  Page 22  |  Page 23  |  Page 24  |  Page 25  |  Page 26  |  Page 27  |  Page 28  |  Page 29  |  Page 30  |  Page 31  |  Page 32  |  Page 33  |  Page 34  |  Page 35  |  Page 36  |  Page 37  |  Page 38  |  Page 39  |  Page 40  |  Page 41  |  Page 42  |  Page 43  |  Page 44  |  Page 45  |  Page 46  |  Page 47  |  Page 48  |  Page 49  |  Page 50  |  Page 51  |  Page 52  |  Page 53  |  Page 54  |  Page 55  |  Page 56  |  Page 57  |  Page 58  |  Page 59  |  Page 60  |  Page 61  |  Page 62  |  Page 63  |  Page 64