Management of heel ulcer

The first sign of a heel ulcer is localized erythema. If pressure is not relieved a 'blister' will develop, which fills first with clear fluid and subsequently with serosanguineous fluid. The base of the blister becomes blue and then black. If pressure is not relieved then deep necrosis may develop. Tense heel blisters should be opened and drained using aseptic precautions.

Urgent pressure relief should be organized. This can be achieved by:

• Regular turning and repositioning of immobile patients to relieve continuous local ischaemia over pressure points

• The pressure relief ankle-foot orthosis (PRAFO) has a washable fleeced liner with an aluminium and polypropylene adjustable frame and a non-slip walking Neoprene base. The patient can wear this orthosis both lying down and walking to avoid pressure on the back of the heel (Fig. 4.27)

• Foam wedges are traditionally used to protect the heels. Heel-protector rings and special heel-relieving splints are available which suspend the heel to protect against further breakdown and allow the ulcer to drain. Heel ulcers on the neuropathic foot can be healed with a total-contact cast (Fig. 4.28a,b).

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