What are the main causes of ulcers in the feet of a diabetic? Ulcers are parts of the surface of an organ (such as the foot or hand) that do not have a dermal covering, which makes the tissues under the skin exposed and exposed to external stimuli. The most important causes of foot ulcers in diabetics are: Peripheral nerve damage This damage leads to the patient not feeling the extra pressure that damages the skin. The result is the appearance of keratoses (such as colourations or increased thickness of the skin) at the points of pressure of the skin between the prominent bones and the ground or shoes as an attempt by the skin to defend itself, but these calluses quickly collapse, resulting in ulcers.
Arteries are narrowed and blocked
Low amount of blood coming to the foot due to narrowing and blockage of arteries leads to skin damage and not being repaired due to insufficient blood reaching it.
Wounds that do not heal
Any wound that lasts longer without healing is considered an ulcer and occurs due to poor healing or poor treatment.
other reasons
Skin diseases may also lead to ulcers, for example blisters may end in ulcers.
Poor venous drainage leads to ulcers, but they often affect the inner lower leg.
Internal infections of the feet may lead to ulcers if they affect the skin above them.
Keratotic ulcers
Why does keratosis cause ulcers in diabetics?
Continued exposure of the points where keratinization appears to high pressures leads to the occurrence of keratotic ulcers as follows:
Under normal conditions, the skin at high pressure points is exposed to reasonable pressure for short periods due to frequent movement of the person''s feet.
The first stage - due to deformities in the joints, the pressure on the skin increases, and due to the lack of pressure sensation, the period of exposure to pressure increases.
Stage Two - The skin reacts to high pressure to form a thick stratum corneum. The victim of these changes is the thin tissue between the skin (which has become thick and hard) and the bone. The result is weak and loose tissue.
Stage III - The subcutaneous tissue continues to weaken as it lies between the hammer and the anvil. Eventually, the tissues may die or a blood pool occurs and this layer collapses completely.
The fourth stage - with the breakdown of this intermediate layer, the skin that has lost its elasticity is cracked and an ulcer is d which is much wider in depth than it appears. This leads to the formation of deep pockets, which are attractive to microbes, especially anaerobes.
What are the areas of the foot?
Before discussing to know the common places of ulcers, it is best to review the parts of the foot so that we agree on what the different names refer to.
The foot is divided into 4 basic areas: the heel - the wrist - the metatarsal - the toes.
The heel (green): is the back part and contains the heel bone.
The wrist (yellow color): It is located in the middle of the foot and contains a group of bones (meaning small bones) which are the bones of the wrist, and are joined by joints.
The metatarsal (red color): It is located between the wrist and the fingers and contains 5 bones, which are the metacarpal bones or metatarsals, each of which is called the first, second and so on.
Fingers (blue color): Each finger contains 3 bones called phalanges (proximal, middle and distal, or also called the first, second, and third), except for the largest finger, which contains only 2.
In addition, the feet have an upper surface called the back of the foot and a lower surface called the stomach (or soles) of the foot.
Finger ulcers
Damage to the peripheral motor nerves leads to atrophy of the small muscles in the sole of the foot. This atrophy causes the muscles to become short, which leads to the deformity of the toes. The result is flexion of the finger at 3 points, which are root, surface, and tip. This deformity is called the claw finger. Flexion increases the chances of exposure to stress and friction at these points. In the end, when these points are exposed to repeated pressure, keratinization occurs in the skin, and ulcers may end up.
At the root of the finger (bottom image), a downward angle develops, which increases pressure on this point against the ground or the sole of the shoe.
At the surface of the finger (middle image), an upward angle arises, which paves the way for friction and pressure with the shoe''s roof, especially if this ceiling is low.
At the tip of the finger (top image) the tip is tilted downward, exposing it to pressure and friction with the ground or the front of the shoe.
Finger root ulcers
The reason for these ulcers is the deformity that occurs in the joint that connects the metacarpal bone to the first phalanx of the finger due to damage to the peripheral motor nerves, which leads to the atrophy of the small muscles in the foot and thus shortens them, making the joint protrude in the direction of the ground, increasing the pressure on the skin at this point.
Finger surface ulceration
The reason for these ulcers is the deformity that occurs in the joint connecting the first phalanx to the second finger due to damage to the peripheral motor nerves, which leads to the atrophy of the small muscles of the foot and thus its shortening, making the joint protrude in the direction of the upper surface of the foot. However, these ulcers are not uncommon because there is no constant pressure on this bulge. However, when wearing shoes with a low ceiling in the front part, the problem arises and ulcers appear.
Finger tip ulceration
The reason for these ulcers is the deformity that occurs in the joint that connects the second phalanx of the finger to the third phalanx due to damage to the peripheral motor nerves, which leads to atrophy of the small muscles of the foot and thus shortens it, which causes the tip of the finger to protrude in the direction of the ground (the claw finger), which increases the pressure on the skin at this point.
Ulceration of the inner sides of the fingers
The reason for these ulcers is the mutual pressure between the fingers, especially when deformities occur in the bones and joints of the finger, which make them protrude sideways. These deformities cause great pain in non-diabetics, but they may not lead to that in diabetics, which paves the way for prolonged stress, and thus distress and ulcers. These ulcers occur more often in patients who wear narrow-toed shoes.
Ulceration of the outer sides of the first and fifth toes
The reason for these ulcers is external pressures on the sides of these toes due to two factors: The first is a natural predisposition in the shape of the foot and the second is the use of narrow shoes from the front. Often there is another immediate cause, such as wounds or the use of chemical agents to treat calluses.
Sore on the belly of the foot (wrist and metatarsal)
Keratotic ulcers in this part occur in Charcot''s disease. The reason for these ulcers is the dislocation and dislocation of the foot joints and bones in this disease, which leads to the bones and joints falling out of their position so that they protrude into the belly of the foot from below and thus the skin is exposed to high pressures at this point with each step, which paves the way for keratosis and ulcers. Note in the left image the protrusion of the foot around the sore. This deformity is called a rocking foot because it resembles the base of a rocking chair.
Sometimes the ulcers arising from Charcot''s disease reach very large sizes and may be so deep that they reach the bone.
Sometimes keratotic ulcers arising from Charcot''s disease occur on the soles of the foot but near the inner side of the foot. The reason for this is the location of the affected joint.
Foot surface ulceration
The metatarsal surface ulceration occurs due to the length of wearing low-ceiling shoes, which causes pressure and friction on the surface of the foot, and it may begin with a slight wound due to the internal suturing of the shoes or the patient''s wound to himself due to scratching or any other reason. Just changing shoes and simple sore care can easily solve the problem. Compare this with ulcers that occur on the bottom of the foot, which represent a great challenge in treatment due to the pressure forced on them while standing and walking
Keratotic ulcers that occur on the sides of the surface of the wrist of the foot occur in patients who are confined to the bed where their feet are tilted towards the outside due to severe fatigue or paralysis, but they receive some kind of care so that they are turned from time to time in bed. This procedure prevents decompensated ulcers (known bed sores) that arise due to constant pressure on the skin without sufficiently turning the patient.
What happens here is that instead of constant pressure on the skin, the pressure is intermittent. Over months and years, the skin is able to react to stress by increasing its layers. This phenomenon is the phenomenon of keratinization. Ultimately, keratoses (calluses) may lead to keratotic ulcers.
In short, the patient who lost the ability to adjust his condition naturally and automatically in response to pressures may find someone to do so from nurses or relatives. However, nothing in this world completely compensates for the automatic means of defense that God has enjoined in man, which we do not even feel their occurrence, because those who carry out the flip do not know exactly how much pressure is placed on a particular part and when they must flip, but they do so automatically without information.
Sore foot edges
A sore on the side of the foot, which in this case is a secondary sore that results from a wound that does not heal. Repeated pressure for long periods of time due to wearing sandals that have stiff and narrow side straps (the sandal that causes ulcers is shown in the picture) led to a keratinic reaction (note the increase in thickness at the edges of the sore) that ended with an ulcer.
Heel ulcers
A sore at the bottom of the heel often arises from wounds caused by a sharp bump in the shoe, a sore, broken glass, etc. These wounds lead to infection and then a sore that does not heal.
A sore behind the heel often develops due to insufficient irrigation (bed sores). Note signs of tissue death and gangrene.
Ankle side sore
Ulcers that occur on both sides of the ankle joint are often caused by external injuries. In these two pictures, the cause of the ulcer was only one, which was wearing an improper or improper orthosis.
Complications of ulcers
How do keratotic ulcers lead to complications in the foot?
Fifth stage - As microbes continue to invade the bottom of the ulcer, the bones become inflamed as well.
Sixth stage - With the prolonged inflammation of the bones, the ulcer turns into a passage for the exit of secretions and pus, which helps the ulcer to continue and establishes it as a chronic disease.
Seventh stage - With time, the inflammation spreads to the foot to include other tissues, and there are many cases in which an ulcer of this type has destroyed most of the foot.
