A 54-year-old man presented with a 1-month history of pain and swelling on the outer left foot and blackening of the left little toe for 15 days. He has type 2 diabetes for 5 years and underwent amputation of the left little toe. On examination, he has an 8.5x7 cm ulcer on the left foot dorsum and plantar aspect with features of peripheral neuropathy and restricted ankle range of motion. He was diagnosed with a left diabetic foot ulcer post little toe amputation that has improved from Wagner grade 4 to grade 2, along with bilateral mixed peripheral neuropathy.

1. SHORT CASE
PRESENTATION
Indrajith K Sudhy
PG Trainee
Department Of General Surgery ,
Gauhati Medical College And Hospital

2. 1. Patient Particulars
• Name – Mr A
• Age – 54 years
• Occupation – Driver
• Resident from – Orang
• SES – Lower middle class
• Date of Admission- 02/02/2020
• Date of Examination - 12/03/2020

3. 2. Presenting Complaint
• Pain & swelling over the outer aspect of left foot -1 month.
• Blackish discoloration of left little toe -15 days.

4. 3. History of Presenting Complaint
• Complained of pain & swelling over the outer aspect of the left
foot towards the little toe following a trivial trauma while walking
one month back.
• Pain was throbbing and localized to the same region, continuous
which aggravates on movements relived by medications. It was
associated with swelling and later mild fever and small quantity
purulent discharge from the lower aspect of foot.
• Following treatment after consultation with a local practitioner,
there was symptomatic improvement in form of reduction of pain
,swelling and discharge ,later there was spontaneous blackening
of tip of left small toe gradually progressed to involve the entire
toe , with reappearance of foot pain since 15 days

5. • He was admitted and underwent amputation of the little
toe , serial debridements and the affected limb presently
has an ulcer over the outer aspect of left foot .
• Tingling, numbness and reduced sensation over both the
foot was present since 2 years.
• No complaints of swelling over the groin, or previous
history of ulcer over the genitals.
• No features of claudication pain.n
• No h/o alteration in bowel and bladder habits ,loss of
weight or appetite, features s/o TIA /LOC, dyspnea, chest
pain or palpitations.

6. 4. Past History
• Known case of type 2 diabetes mellitus on
irregular medication for the past 5 years .
• No other known comorbidities.(Hypertension ,
chronic kidney disease, CAD,TB, Hansen’s
disease, hypo or hyper thyroidism,
rheumatological disorders, varicose veins )
• No previous hospitalization or surgeries in the
past.
5. Family History
• No known TB, hematological, cardiac or
vasculitis related illnesses.

7. 6. Personal & Social History
• Tobacco in the form of smoking – 5 pack
years.
• Occasional alcohol consumption for 12 years.
• Married and living with wife and 2 children.

8. 7. Physical Exam & General Survey
• Examined the patient with informed consent,
in a well lit room, after adequate exposure.
• Patient is lying comfortably with both limbs
stretched on the examination couch.
• Average built – 165 cm
• BMI - 20.8 Kg/m2
• KFS –80
• Gait : limping /antalgic (pain)

9. • Skin – Trophic changes of lower extremity. No hypopigmented patches
noted.
Eyes – no icterus, pink palpebral conjunctiva
Oral cavity – normal
• Neck – normal
• Fingers & Nails – no joint swelling or deformity , Onychodystrophy of
bilateral toe nails ,no clubbing, koilonychia
• No significant generalized inguinal lymphadenopathy
Vital Signs –
• Afebrile
• PR – 72 beats/min in R radial artery; regular in rhythm with normal vessel
wall & character and without radioradial or radio-femoral delay.
• BP – 130/80 mmHg in right arm supine position.
• RR – 14 cycles/min and regular.

11. 8. Examination of Lower Limbs
Right Left (affected)
Attitude Neutral 10◦ of dorsiflexion at ankle
Deformities nil 5th toe amputated
Skin hair and nails Dry and scaly skin,
sparse hair,
onychodystrophy
Ulcer present ,Dry and scaly skin with
hyperpigmentation over the dorsal aspect ore
around the ulcer , sparse hair, onychodystrophy
• Single ulcer located over the left foot dorsum extending to the plantar aspect
occupying the distal outer aspect .
• Irregularly curved margin , with sloping edge all around with red ,blue and white
zones.
• Floor is formed by healthy granulation tissue ,with minimal slough interspersed
and with extensor tendon of 4th toe exposed ,minimal serous discharge present
• No gangrenous changes over the limb , No dilated veins , ankle joint grossly
normal.
• Areas of pressure points – normal.

12. PALPATION
• Temperature normal over the ulcer and surrounding area.
• Ulcer and the surrounding area is mildly tender
• Measurements of the ulcer : 8.5 * 7 cm
• Other inspector findings are confirmed.
• Base : formed by the muscles over dorsum and plantar, mildly indurated
,granulation tissue bleeds on touch,distal portion of the fifth metatarsal is palpable
beneath the granulation tissue.
• Web spaces normal. Long bones normal.
• Capillary filling and refill time - normal (b/l)
• No inguinal lymphadenopathy (b/l)
• No peripheral nerve thickening

14. Right Left (affected)
Peripheral pulse DPA (+); ATA (+); PTA (+); Pop. A (+);
Femoral A(++); RA (++); UA (++); Br A
(++); Ax A (++); Subcl A (++); Carotid A
(++); STA (++).
DPA (+); ATA (+); PTA (+); Pop. A (+);
Femoral A(++); RA (++); UA (++); Br A
(++); Ax A (++); Subcl A (++); Carotid A
(++); STA (++).
Neurological
sensation-Vibration
proprioception,pain
monofilament test,
Ankle reflex
knee reflex
Power
Diminished
0
+
N
Diminished
0
+
N
Measurements
Length 85 cm 85 cm
Muscle bulk 33 (ak), 31(calf) 33 (ak), 31(calf)
Range’movements
Flexion
Extension
Pronation
Supination
Knee
20◦
50◦
30◦
50◦
N
<10◦
40◦
10◦
20◦
N

15. 9. Systemic Examination
• Respiratory System
Bilateral vesicular breath sounds heard; no added sounds.
• Abdomen and perineum
Soft, non tender, no visceromegaly, normal bowel sounds
heard. Perineal examination normal.
• Cardiovascular System
S1 S2 heard. No abnormal sounds heard.
• Central Nervous System and spine.
Normal.

16. 10. Summary
• A 54 YO ,type 2 diabetic male patient come with
a complaint of pain ,swelling over the left little
toe ,followed by gangrene an purulent discharge
from the same site for 15 days. He underwent
rayamputation of the little toe and is currently
have a healing ulcer over the lateral ,dorsal and
plantar aspect of left foot .
• Clinical exam significant for 8.5*7cm ulcer with
features of peripheral neuropathy and restriction
of range of movements of ankle joint.

17. 11. Diagnosis
Diabetic foot ulcer left side ,post ray amputation
status left 5th toe (Wagner grade 4 improved to
grade 2 ) with bilateral mixed peripheral
neuropathy .
Diabetic foot ulcer – PEDIS system
P1 E(8x7.5) D2 I1 S2

18. Thank You
ALL THE BEST