DiabeticDiabetic FootFoot(siti zarina)(siti zarina) 1

Why you should wake up and focus on this presentation?

2006 Third National Health Morbidity Surveya) prevalence rate of diabetes mellitus has been

reported to have increased from 8.3% in 1996 to 14.9% in 20061

b) prevalence of lower limb amputation among patients with diabetes was 4.3%.

c) Our MBBS exam

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HISTORY

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General and medical history

- Hx presenting foot complain and duration- Duration of diabetes, management, control

and complication- Social history- Allergy and any medication- Past medical and surgical history- Habits: walks barefoot? Wets feet at work?

Wear socks? Walks a lot?

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History of foot problems

- Daily activity and current diabetic foot status- What footwear?- Foot care?- Callus formation- Deformities and previous surgery?- Neuropathy and ischemic symptoms?- Skin and nail problems?

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History of ulcers- Site, size, duration, odour, type of drainage- Precipitating factor, trauma?- Recurrences?- Associated infections symptoms- Any hospitalizations and what treatment- Wound care- Patient compliance- Previous trauma or surgery- Features of Charcot joint

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Physical examination

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a) General : any sign of inflammationb) Local examination : compare both limbs.

Check the normal one first

Musculoskeletal status

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Attitude and postureAttitude and posture

Orthopaedic deformitiesOrthopaedic deformities

Limited joint mobility, muscle strength

Limited joint mobility, muscle strength

Tendo-Archilles contractures/equinus/foot drop

Tendo-Archilles contractures/equinus/foot drop

Gait evaluationGait evaluation

Plantar pressure measurementPlantar pressure measurement

Skin and nails of footSkin and nails of foot

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Skin appearance: color, texture, turgor, quality and dry skin

Calluses, heel fissures, cracking of skin

Nail appearancesPresence of hair

Ulceration, gangrene, infection

Interdigital lesions, tinea pedis

Vascular status of foot

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Pulses Pulses

Capillary refill timeCapillary refill time Edema Edema

Color change Color change

Temperature gradientTemperature gradient

Venous filling timeVenous filling time

Changes of ischemiaChanges of ischemia

Neurological status of foot

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Vibration perception

Pressure and touch- monofilament 10gm Semmes Weinstein, cotton wool

Pain – pin prick

Two point discrimination

Temperature perception

Deep tendon reflexes – ankle and knee

Clonus testing, Babinski test and Romberg test

Evaluation of foot wear

• Type and condition of shoes and sandals• Fit• Shoe wear, pattern of wear, lining wear• Foreign bodies• Insoles, orthoses

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Investigation

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General Glucometer/ Random Blood Sugar, Fasting blood sugar HbA1C FBC U&E ESR UFEME –Ketonuria, CNS Wound and blood culture and sensitivity

IMAGING X-rays of foot (AP, Lateral) (to look for soft tissue gas , Charcot jt, fracture,

osteomyelitis) CT scan Bone scan and MRI

Vascular assessment- Doppler , ankle brachial indices (normal value= 1.1. if <0.9, abnormal)Plantar foot pressure

Diabetic foot ulcer

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Neuropathy

Peripheral vascular disease

Abnormal foot pressure

Hyperglycemia

Trauma

Foot deformity Limited joint mobility

Previous ulceration and amputation

Poor vision

Chronic renal disease

Old ageCondition of

diabetes

Neuropathy

Peripheral vascular disease

Abnormal foot pressure

Hyperglycemia

Trauma

Foot deformity Limited joint mobility

Previous ulceration and amputation

Poor vision

Chronic renal disease

Condition of diabetes

Pathogenesis

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Somatic neuropathy- reduced perception to pain-Diminished proprioception-Clawing of toes

Autonomic neuropathy-Absent sweating-Dry skin fissures-Altered blood flow and regulation-Distended foot veins; warm foot-Charcot neuroarthropathy

Peripheral vascular disease-Claudication-Rest pain-Cold extremities-Reduced foot pulses

Increased foot pressure Callus

formation

Foot ischemia

Foot ulceration Gangrene

Infection

Amputation

Connective tissue changes-Limited joint mobility-Orthopedic disorder

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Wagner’s foot ulcer classification

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Treatment

• Debridement• Wound care• Reduction of plantar pressure (Off loading)• Treatment of infection• Vascular management of ischemia• Medical Rx of co-morbidities• Surgical management• Reduce risk of recurrence

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Debridement

• Surgical debridement– Involve removal of all non-viable tissue or bone until healthy bleeding

soft tissue or bone are encountered. – Abscess: immediate I & D.– Osteomyelitic bones, joint infection, gangrene digits: require

resection or partial amputation.

• Other type of debridement: a) mechanical (surgical debridement, high pressure irrigation,

wet to dry dressing),b) Enzymaticc) Autolytic

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Wound care• Done following debridement.• Dressing: normal saline and others (e.g: transparent films,

foam, hydrocolloids, calcium alginates, gauze pads, collagen dressings)

• Ulcer is covered to avoid contamination and trauma.• Choice of dressings or topical agents depends on the health

care provider’s experience, type and site of ulcer, costs involved and patient’s preferences

Off-loading

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• Reduce the pressure to the ulcer.• Thus, reducing the trauma to the ulcer and allowing it to heal.• Example:

– Total contact casting– Total non-weight bearing– Removable walking braces with rocker bottom soles– Foot casts or boot– Total contact orthoses– Healing sandal– Patellar tendon bearing braces– Half shoe or wedge shoes– Healing sandal- surgical shoe with molded plastizote insole

Total contact casting

Healing sandal

Cast boot

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Treatment of infection

• Early incision and drainage• Empirical broad-spectrum antibiotic.

Vascular management of ischemia

- Vascular supply should be assessed early before surgery intervention

Treat other medical co-morbidities

• DM is a multi-organ systemic disease.• Multi-disciplinary approach.

Surgery

• Remove structurally deformed foot which my give rise to high pressure areas causing ulcers that do not heal with off loading technique or therapeutic foot wear

• Amputation- gangrene and ulcers with osteomyelitis

• Includes removal of infected bone or joint e.g:– metatarsal head resection, partial calcanectomy, exostectomy,

sesamoidectomy and digital arthroplasty

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I & D, debridement, amputation

Empirical regimena) Mild mod infection- gram +ve- 1-2 weeksb) Severe and life threatening-+ve, -ve, enterococci, anaerobic -More than 2 weeksc) If osteomyelitis and have not been amputated: 2-8 weeks

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Hypertrophic osteoarthropathy currently seen primarily in patients with diabetes who have peripheral neuropathy

An abnormal vascular inflow producing bony

resorption, bony weakening

Etiology

The traumatic etiology implies fracture or stress fracture

without protective sensation→inherent motion applied to a nonimmobilized

fracture.

Neurotraumatic Neurovascular

Hypertropic response

Amputation

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3 D’s

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• Damned Nuisance - dt pain, gross malformation, recurrent sepsis, severe loss of function

• Dead - PVD, trauma, burns, frostbite

• Dangerous - malignant tumours, potentially lethal sepsis, crush injury

Complication

Early • Breakdown of skin flaps• Gas gangrene

Late• Skin- eczema, ulcer• Muscle- improper use

of prosthesis• Artery- ulcer• Nerve- pain & tender• Phantom limb

Patient education

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Patient education

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References • http://www.hrsa.gov/leap/patienteducation.htm

• www.emedicine.com• Boon et al. Davidson’s principle and Practice

of medicine. 20th edition, Churchill Livingstone Elsevier 2006. page;844-846.

• Management of diabetic foot, CPG 2004• http://care.diabetesjournals.org/content/26/1

0/2848.full

• http://www.wagnergradeposter.com/012wagnerpic.jpg

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Thank you =)

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