1. Crestodina, Lea R.

Article Content

Neuropathic ulcers are a serious and potentially fatal complication of diabetes. Lower extremity amputations are preceded by a neuropathic foot ulcer 84% of the time.1 A lower limb amputation, particularly those associated with ischemic disease, has a 5-year mortality rate of 55%.2 Although the amputation mortality statistics are alarming, the statistics on diabetes remain even more alarming. In 2010, 25.8 million Americans had diabetes with a prevalence of 8.3%. By 2012, this number increased to 29.1 million Americans or 9.3% of the population.3 It is estimated that as many as 60% to 70% of all patients with diabetes will develop some degree of neuropathy.4 Sensory neuropathy leads to repetitive, painless trauma, which is the primary etiology of neuropathic ulcers.


The good news is that there has been a significant reduction in the lower extremity amputation rate over the last decade.5 This has occurred during a time when the overall prevalence of diabetes was increasing. The use of orthopedic treatments for neuropathic ulcers also increased during this time from 26.0% to 63.3%. These treatments included such things as total contact casting and Achilles tendon release.


A critical component of basic knowledge of WOCNCB certified wound care nurse includes prevention of lower extremity amputations and, if ulcers do occur, measures to heal them as soon as possible. These ulcers present a unique challenge. They require much more than just topical wound care. A team approach, which may include an endocrinologist, diabetes educator, surgeon, podiatrist, and infectious disease specialist, is essential to neuropathic wound management and healing. The certified wound nurse must have a solid understanding of off-loading, blood glucose management, medical nutritional therapy, moist wound healing, serial debridement of slough and callus (if perfused), treatment of infection, and other adjunctive therapies such as bioengineered tissue use, hyperbaric therapy, and/or revascularization.


For the novice wound care nurse, or one who does not see many neuropathic wounds, differential assessment and management of foot and leg ulcers can be challenging and confusing. Characteristics of lower extremity ulcers can be similar or overlapping, particularly with mixed disease making clinical decision-making difficult. When preparing for the WOCNCB wound care certification examination, one helpful technique to tackle challenging content is to spread the learning of that content over time and into small chunks of content. This is called distributed practice. In a monograph that reviewed many learning strategies, distributed practice and practice testing were found to be two of the most effective learning strategies.6 Breaking content into relatively short study episodes that use or repeat the same material can help improve the recall of concepts and practice such as when taking the certification examination. In preparing for the certification examination, flashcards can be a very effective study tool and lend themselves to short study periods over an extended time. Flashcards can be prepared by the learner or commercially published and used properly and can help you succeed on the wound care certification examination. WOCNCB has prepared a set of flashcards to aid in preparation for the certification examination. These flashcards are an evidence-based method of preparation to assist you in preparing for the WOCNCB wound care examination based upon an effective learning strategy: distributed practice.


1. Pecoraro RF, Reiber GF, Burgess EM. Pathways to diabetic limb amputation: basis for prevention. Diabetes Care. 1990;13(5):513-521. [Context Link]


2. Moulick PK, Mtonga R, Gill GV. Amputation and mortality in new-onset diabetic foot ulcers stratified by etiology. Diabetes Care. 2003;26:491-494. [Context Link]


3. Accessed August 1, 2014. [Context Link]


4. Alencherry J, DeLucia F. Podiatric diabetology battling an epidemic from a lower extremity approach. Pract Diabetol. November/December 2013:28-30. [Context Link]


5. Belatti DA, Phisitkul P. Declines in lower extremity amputation in the U.S. Medicare population, 2000-2010. Foot Ankle Int. 2013;34(7):923-931. [Context Link]


6. Dunlosky J, Rawson KA, Marsh EJ, Nathan MJ, Willingham DT. Improving students learning with effective learning techniques: promising directions from cognitive and educational psychology. Psychol Sci Public Int. 2013;14(1):4-58. [Context Link]


Sample Questions

1. What are the essential elements to healing a neuropathic foot ulcer?


a. Off-loading, debridement, compression


b. Off-loading, protein supplements, debridement


c. Off-loading, debridement, infection management


d. Off-loading, debridement, orthotics



Content outline: 010401


Cognitive level: Recall


Answer: C. The essential elements for healing a neuropathic foot ulcer are: offloading, debridement, and management of infection. These elements are based on current research. Offloading the wound is essential to relieve the pressure or causative agent. This is especially challenging on the plantar surface, where many of these lesions occur. A 2013 study done by Fife et al1 looked at the large gap that exists between the evidence for off-loading and the practice of off-loading. Serial debridement has been shown to increase healing times and is necessary if there is devitalized tissue in the wound and/or surrounding callus. Management of infection is critical for several reasons: (1) These wounds can become infected easily due to location and elevated blood sugars. (2) Soft tissue infection can lead to osteomyelitis that can be limb and life threatening. (3) Infection is often difficult to detect due to a blunted inflammatory response in this population.


Compression is not indicated for neuropathic ulcers; it is the gold standard for venous insufficiency. Protein supplements could be used if the patient is malnourished, but typically these patients are well nourished and do not require supplementation. Orthotics are used to correct an abnormal gait pattern but are not used for offloading.


1. Fife CE, Carter MJ, Walker D, Thomson B, Eckert KA. Diabetic foot ulcer off-loading: the gap between evidence and practice. Data from the US Wound Registry. Adv Wound Care. 2014;27:310-316. [Context Link]


2. Lebrun E, Tomic-Canic M, Kirsner R. The role of surgical debridement in healing of diabetic foot ulcers. Wound Repair Regen. 2010;18(5):433-438.


3. Driver VR, LeBretton JM, Landowski MA, Madsen JL. Neuropathic wounds: the diabetic wound. In: Acute and Chronic Wounds: Current Management Concepts. 4th ed. St Louis, MO: Elsevier; 2012:239-243.


2. You have performed 5.07 monofilament testing on your patient and it reveals inability to feel the monofilament in 4 out of 9 areas. Your patient education should include:


a. See a vascular surgeon urgently


b. Do not ever walk barefoot


c. This is a normal finding with diabetes


d. See an orthotist as soon as possible



Content Outline: 010404


Cognitive Level: Application


Answer: B. Monofilament testing is a way of testing for sensory neuropathy. Typically the Semmes-Weinstein 5.07 monofilament is applied perpendicularly to 9 or 10 areas on the plantar surface of the foot and one area of the dorsum. Any inability to feel sensation is considered lack of protective sensation. Education should include not to EVER walk barefoot, even from the bed to the bathroom.


A vascular surgeon is needed for critical ischemia that is measured by an ankle-brachial index, not monofilament testing.


Lack of sensation in 4 out of 9 areas is not a normal finding. It indicates lack of protective sensation.


An appointment with an orthotist is indicated if there are foot deformities. This question does not imply that there are foot deformities.



1. Driver VR, LeBretton JM, Landowski MA, Madsen JL. Neuropathic wounds: the diabetic wound. In: Acute and Chronic Wounds: Current Management Concepts. 4th ed. St Louis, MO: Elsevier; 2012:230-243.


3. Neuropathic ulcers are caused by:


a. Venous insufficiency


b. Out of control blood sugars


c. Inadequate perfusion


d. Repetitive painless trauma



Content Outline: 010401


Cognitive Level: Recall


Answer: D. The etiology of neuropathic ulcers is repetitive, painless trauma. To heal an ulcer with this etiology, the etiology must be removed. This is the purpose of off-loading. Venous insufficiency is characterized by edema, palpable DP and PT pulses, hemosiderosis, and lipodermatosclerosis. Out-of-control blood glucose levels may contribute to infection, delayed wound healing, and development of osteomyelitis, but are not a direct cause of neuropathic foot ulcers. Inadequate perfusion may be a detriment to healing but is not a direct cause of neuropathic ulcers. It may also impede healing in a neuropathic ulcer.




1. Driver VR, LeBretton JM, Landowski MA, Madsen JL. Neuropathic wounds: the diabetic wound. In: Acute and Chronic Wounds: Current Management Concepts. 4th ed. St Louis, MO: Elsevier; 2012:230-243.