These should include neurological, vascular, laboratory and radiological investigations as described in Chapter 1.
While it is not necessary to X-ray every stage 3 foot with a presenting ulcer, it may be advisable to do so in the following circumstances:
• When the history suggests that the patient may have trodden on a foreign body
• When the ulcer probes to bone, clinically suggesting osteomyelitis
• If there are clinical signs of infection
• When there is unexplained pain or swelling which may be related to neuropathic fracture or Charcot's osteoarthropathy
• When the ulcer has been present for longer than 1 month.
Radiological studies of diabetic feet have revealed a high prevalence of fractures in neuropathic patients and most of these had not been previously diagnosed.
Having completed the history, examination and investigations, it is possible to make a firm diagnosis of ulceration either in the neuropathic foot or the neuroischaemic foot. The characteristic features are described in Table 4.1.
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