Education And Debate

A Difficult Case Should an elderly diabetic woman with a right below knee amputation and an infected sore on her left heel be operated on for a fractured hipReconstruct the blood supply, debride the ulcer, and pin the hipFirst assess the ulcerIf no other major disease, fix the fractureOperate to relieve the pain

BMJ 1994; 308 doi: https://doi.org/10.1136/bmj.308.6927.517 (Published 19 February 1994) Cite this as: BMJ 1994;308:517

A Difficult Case Should an elderly diabetic woman with a right below knee amputation and an infected sore on her left heel be operated on for a fractured hip

  1. M Heim,
  2. Y Zievner,
  3. H Nadorvna,
  4. M Azaria

    Maintaining independent mobility is a high priority in elderly patients, both for their quality of life and because of the increased morbidity and mortality associated with being confined to bed. M Heim and colleagues present a difficult case that illustrates the problems arising when a patient with a below knee amputation and an infected pressure sore on her remaining heel required an elective orthopaedic operation to restore a degree of independent mobility. Five experts not concerned with the case also give their views on how it might have been managed.

    Case report

    A 68 year old diabetic woman was admitted to hospital with an intratrochanteric fracture of her left leg. She had had insulin dependent diabetes for 20 years, and at the time of admission was wheelchair bound with a right below knee amputation and a decubitus ulcer on her left heel.

    The amputation had been performed six years previously because of a foot infection due to arterial insufficiency. After this the patient had learnt to walk with a prosthetic limb despite being obese and having poor vision because of diabetic retinopathy.

    The pressure sore had developed three and a half years later while she was in hospital with diabetic coma due to lobar pneumonia. It was treated with local dressings and several courses of systemic antibiotics.

    For the year after her discharge from hospital she had lived at home with her two sons, mobile in her wheelchair and receiving regular physiotherapy to prevent flexion contractures of her hips and knees. The ulcer had healed on its plantar surface, but a round wound about 5 cm in diameter on the posterolateral inframaleolar surface had remained static for several months despite local treatment. It had a central, hard, black crust surrounded by an infected area with wet, foul smelling necrotic tissue. Clinical assessment …

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