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Hello, Is it ever appropriate to classify a wound as " diabetic ulcer" if on the upper limb? I was under the impression that diabetic ulcers are the foot? Thank you
Oct 16, 2020 by Melissa Khoo,
2 replies
Elaine Horibe Song
MD, PhD, MBA
Hi Melissa

Thanks for your question. Peripheral neuropathy not only affects feet of patients with diabetes, but can also affects other anatomical areas such as their hands. This peripheral neuropathy appears to affect the hands and feet of diabetics in a similar "stocking-glove" fashion. Although rare, there have been reports of diabetic hand ulcer as a complication of diabetes (prevalence of hand ulcers ranges from 0.37-3.2% among patients with diabetes). Peripheral neuropathy is present in most patients diagnosed with diabetic hand ulcers (~88%). Factors leading to diabetic hand ulcers include unawareness of decreased sensation in hands and local trauma. Other risk factors include long duration of disease, poor metabolic control and delayed presentation. 

For more details, please check: 
- A clinical analysis of diabetic patients with hand ulcer in a diabetic foot centre: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2905609/
- The diabetic hand: a forgotten complication? https://pubmed.ncbi.nlm.nih.gov/19217319/
- DFU - Intro and Assessment (Pathophysiology, Coding sessions) https://woundreference.com/app/topic?id=diabetic-foot-ulcer-introduction-and-assess#icd10
Oct 16, 2020
Eugene Worth
MD, M.Ed., FABA, ABPM/UHM
Melissa:

Over the years, I have seen several diabetic patients with neuropathic ulcers of the hands. I'm just going to elaborate on a couple of points that Dr. Song raised.

First, there are neuropathic ulcers to the upper extremity. A number of these ulcers are associated with restricted blood flow and critical upper extremity limb ischemia. Yes, these can be a threat to limb.

Second, although you have all of the characteristics of a lower extremity diabetic foot ulcer ... except in the hands, these patients are not candidates for hyperbaric oxygen therapy. The reason (though convoluted) is ... the ulcer isn't a lower extremity ulcer. Don't ask. I didn't create the rule. But, I do know that treating these patients while calling it a neuropathic diabetic ulcer ... would be considered fraud in the USA.

Finally, it is rare to see this type of ulcer. I've probably seen a handful in over 15 years in wound care and hyperbaric medicine.

Therapy is no different than in the diabetic foot. The first key is blood flow, blood flow, blood flow. The next is removing any recurring micro-trauma in the neurogenic extremity. I would use the same flowchart as found in Wound Reference for lower extremity. It will work equally well.

All the best. Hope this helps.
Oct 16, 2020
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