ANATOMY AND PHYSIOLOGY OF DIABETIC FOOT:

The foot is an extremely complex and flexible structure. It is composed of a network of bones, joints, ligaments, and numerous muscles that work together to provide the body with support, forward propulsion, adaptation to uneven surfaces, and absorption of shock. The complex interaction of foot bones and joints allows the vast range of motion exhibited by the foot during walking. Abnormal mechanical loading of the foot, resulting in repetitive pressure applied to the plantar aspect of the foot during walking, has an important role in the development of Diabetic Foot Disease.

The systematic examination of weight transmission and the walking mechanisms offers perhaps one of the key elements in understanding the development of foot ulcerations in patients with diabetes. In the standing position, the body weight is transmitted from the femur and tibia through the heel bones (talus and calcaneus) and the heads of the metatarsals to the ground. During walking, the calcaneus has an important role in the first two segments (heel strike and midstance) in providing optimal gait for energy absorption and weight bearing. In the third segment of walking, the muscles, tendons, and ligaments tighten to lift the calcaneus off the ground (heel rise), and then the foot regains its arch in preparation for the last segment (toe push-off).

The shearing forces during dynamic walking, in addition to the balance between the forces of the pushing down of the body weight and the pushing up of the ground reactive forces, create friction and compressive forces on the foot.Abnormalities in foot biomechanics may result in a dysfunctional gait and can lead to structural changes in the foot that increase the risk of ulceration and subsequent amputation. Loss of sensation, especially at pressure points, may lead to persistent stress, which may result in development of a bunion and subsequent skin breakdown and ulcer formation. The deep aspect of the plantar aponeurosis sends septa that divide the plantar aspect of the foot into three major compartments: medial, central, and lateral (Figure 2).

[(Figure 2). Schematic anatomic diagram of forefoot compartments. Deep soft tissue infection is likely to spread along these compartments. C = central compartment; D = dorsal compartment; L = lateral compartment; m = medial compartment.]

These compartments contain the long flexor tendons and the tendons of intrinsic muscles of the foot covered by synovial sheaths. Extension of infection into these compartments might increase the intra compartmental pressure, which may further interfere with the blood supply to the distal portions of the foot and thus exacerbate the problem of ulceration and poor healing.

Every cell in the human body needs energy in order to function. The body’s primary energy source is glucose, a simple sugar resulting from the digestion of foods containing carbohydrates (sugars and starches). Glucose from the digested food circulates in the blood as a ready energy source for any cells that need it. Insulin is a hormone or chemical produced by cells in the pancreas, an organ located behind the stomach. Insulin bonds to a receptor site on the outside of cell and acts like a key to open a doorway into the cell through which glucose can enter. Some of the glucose can be converted to concentrated energy sources like glycogen or fatty acids and saved for later use. When there is not enough insulin produced or when the doorway no longer recognizes the insulin key, glucose stays in the blood rather entering the cells.

INTRODUCTION OF DIABETIC FOOT:

Diabetic foot is an umbrella term for foot problems in patients with diabetes mellitus. It is better known as diabetic foot ulcer. Diabetic foot ulcer is one of the major complications of Diabetes mellitus. It occurs in 15% of all patients with diabetes and precedes 84% of all lower leg amputations.[1] Major increase in mortality among diabetic patients, observed over the past 20 years is considered to be due to the development of macro and micro vascular complications, including failure of the wound healing process. Wound healing is a ‘make-up’ phenomenon for the portion of tissue that gets destroyed in any open or closed injury to the skin. Being a natural phenomenon, wound healing is usually taken care of by the body’s innate mechanism of action that works reliably most of the time. Key feature of wound healing is stepwise repair of lost extracellular matrix (ECM) that forms largest component of dermal skin layer. Therefore controlled and accurate rebuilding becomes essential to avoid under or over healing that may lead to various abnormalities. But in some cases, certain disorders or physiological insult disturbs wound healing process that otherwise goes very smoothly in an orderly manner. Diabetes mellitus is one such metabolic disorder that impedes normal steps of wound healing process. Many histopathological studies show prolonged inflammatory phase in diabetic wounds, which causes delay in the formation of mature granulation tissue and a parallel reduction in wound tensile strength

DEFINITION OF DIABETIC FOOT:

“Infection, ulceration and/or destruction of deep tissues associated with neurological abnormalities and various degrees of peripheral vascular disease in the lower limb of a diabetic client is known as diabetic foot.” (WHO, 1985)

EPIDERMINOLOGY OF DIABETIC FOOT:

In a study to determine prevalence of diabetic foot in India, the prevalence of infection noted was 6-11% and prevalence of amputation was 3% in type 2 diabetic patients. In another Indian study, the prevalence of diabetic foot ulcers in the clinic population was 3.6% as noted by Viswanathan Sociocultural practices such as barefoot walking, religious practices like walking on fire, use of improper footwear and lack of knowledge regarding foot-care attributes towards increase in the prevalence of foot complications in India.17 Not only the prevalence of diabetic foot ulcers, but Indian studies have also reported high recurrence of foot infection to be more common among Indian diabetic patients (52%).

CAUSES AND RISK FACTORS OF DIABETIC FOOT:

IN BOOK IN CLIENTSeveral risk factors increase a person with diabetes chances of developing

foot problems and diabetic infections in the legs and feet.

Footwear: Poorly fitting shoes are a common cause of diabetic foot problems. If the patient has red spots, sore spots, blisters, corns, calluses, or consistent pain associated with wearing shoes, new properly fitting footwear must be obtained as soon as possible. It also develops if the patient has common foot abnormalities such as flat feet, bunions, or hammertoes, prescription shoes or shoe inserts may be necessary.

Nerve damage: People with long-standing or poorly controlled diabetes are at risk for having damage to the nerves in their feet. Because of the nerve damage, the patient may be unable to feel their feet normally. Also, they may be unable to sense the position of their feet and toes while walking and balancing. Also a person with diabetes may not properly sense minor injuries (such as cuts, scrapes, blisters), signs of abnormal wear and tear (that turn into calluses and corns), and foot strain. A person who has diabetes may not be able to perceive a stone. Its constant rubbing can easily create a sore.

Poor circulation: Especially when poorly controlled, diabetes can lead to accelerated hardening of the arteries or atherosclerosis. When blood flow to injured tissues is poor, healing does not occur properly.

Trauma to the foot: Any trauma to the foot can increase the risk for a more serious problem to develop.

Infections

o Athlete's foot, a fungal infection of the skin or toenails, can lead to more serious bacterial infections and should be treated promptly.

o Ingrown toenails should be handled right away by a foot specialist. Toenail fungus should also be treated.

Smoking: Smoking any form of tobacco causes damage to the small blood vessels in the feet and legs. This damage can disrupt the healing process and is a major risk factor for infections and amputations. The importance of smoking cessation cannot be overemphasized.

Present ( she always wears chappals)

Present ( She has diabetes for 15 yrs)

Present

Present

Not present

Not present

PATHOPHYSIOLOGY OF DIABETIC FOOT:

Diabetics are prone to foot ulcerations due to both neurologic and vascular complications. Peripheral neuropathy can cause altered or complete loss of sensation in the foot and /or leg. Similar to the feeling of a "fat lip" after a dentist's anesthetic injection, the diabetic with advanced neuropathy looses all sharp-dull discrimination. Any cuts or trauma to the foot can go completely unnoticed for days or weeks in a patient with neuropathy. It's not uncommon to have a patient with neuropathy tell you that the ulcer "just appeared" when, in fact, the ulcer has been present for quite some time. There is no known cure for neuropathy, but strict glucose control has been shown to slow the progression of the neuropathy. Charcot foot deformity occurs as a result of decreased sensation. People with "normal" feeling in their feet automatically determine when too much pressure is being placed on an area of the foot. Once identified, our bodies instinctively shift position to relieve this stress. A patient with advanced neuropathy looses this important mechanism. As a result, tissue ischemia and necrosis may occur leading to plantar ulcerations. Microfractures in the bones of the foot go unnoticed and untreated, resulting in disfigurement, chronic swelling and additional bony prominences.

Microvascular disease is a significant problem for diabetics and can lead to ulcerations. It is well known that diabetes is called a small vessel disease. Most of the problems caused by narrowing of the small arteries cannot be resolved surgically. It is critical that diabetics maintain close control on their glucose level, maintain a good body weight and avoid smoking in an attempt to reduce the onset of small vessel disease.

CLASSIFICATION OF DIABETIC FOOT ULCERS

Most experts use some variant of the classification system developed by Wagner and most currently modified by Brodsky.

DEPTH CLASSIFICATION DEFINITION TREATMENT0 At-risk foot, no ulceration Patient education,

accommodative footwear, regular clinical examination

1 Superficial ulceration, not infected

Offloading with total contact cast (TCC), walking brace, or special footwear

3 Deep ulceration exposing tendons or joints

Surgical debridement, wound care, offloading, culture-specific antibiotics

4 Extensive ulceration or abscess

Debridement or partial amputation, offloading, culture-specific antibiotics

Ischemia ClassificationA Not ischemicB Ischemia without

gangreneNon invasive vascular testing, vascular consultation if symptomatic

C Partial (forefoot) gangrene Vascular consultationD Complete foot gangrene Major extremity amputation,

vascular consultation

GRADING OF FOOT:

Grade 1: Superficial Diabetic Ulcer

Grade 2: Ulcer extension

1. Involves ligament, tendon, joint capsule or fascia2. No abscess or Osteomyelitis

Grade 3: Deep ulcer with abscess or Osteomyelitis

Grade 4: Gangrene to portion of forefoot

Grade 5: Extensive gangrene of foot

In Client: Client is in the depth classification of 3, grade 2 and the ischemia classification of ‘A’ according to the classification of Wagger.

CLINICAL MANIFESTATIONS OF DIABETIC FOOT:

IN BOOK IN CLIENTEarly sign include:

- Redness of the skin- Blistering -Signs of irritation.

In the later stages:

- The person may encounter an open wound that drains fluid onto socks or bedding- Infection on open wound- Infected open wound develop swelling, redness, and drainage of pus- Fever and blood sugar levels may be higher than usual

Not Present

All the late stages symptoms present in the patient

DIAGNOSTIC INVESTIGATIONS:

IN BOOK IN CLIENTMedical evaluation should include a thorough history and physical examination and may also include laboratory tests, x-ray studies of circulation in the legs, and consultation with specialists.

History and physical examination: First, the questions about their symptoms and injured area will examine them. This examination should include the patient's vital signs (temperature, pulse, blood pressure, and respiratory rate), examination of the sensation in the feet and legs, an examination of the circulation in the feet and legs, a thorough examination of any problem areas. For a lower extremity wound or ulcer, this may involve probing the wound with a blunt probe to determine its depth.

Laboratory tests:

-Complete blood cell count, or CBC: which will assist in determining the presence and severity of infection. A very high or very low white blood cell count suggests serious infection.

- Blood sugar testing: either by fingerstick or by a laboratory test.

-Depending on the severity of the problem, the doctor may also order kidney function tests, blood chemistry studies (electrolytes), liver enzyme tests, and heart enzyme tests to assess whether other body systems are working properly in the face of serious infection.

-X-rays: The x-rays studies of the feet or legs to assess for signs of damage to the bones or arthritis, damage from infection, foreign bodies in the soft tissues. Gas in the soft tissues, indicates gangrene - a very serious, potentially life-threatening or limb-threatening

Done

Done

Done

Done

infection.

-Ultrasound: The doctor may order Doppler ultrasound to see the blood flow through the arteries and veins in the lower extremities. The test is not painful and involves the technician moving a non-invasive probe over the blood vessels of the lower extremities.

-Consultation: The doctor may ask a vascular surgeon, orthopedic surgeon, or both to examine the patient. These specialists are skilled in dealing with diabetic lower extremity infections, bone problems, or circulatory problems.

-Angiogram: If the vascular surgeon determines that the patient has poor circulation in the lower extremities, an angiogram may be performed in preparation for surgery to improve circulation.

Done

Done

Not Done

MANAGEMENT OF DIABETIC FOOT:

The management of diabetic foot ulcers requires offloading the wound by using appropriate therapeutic footwear, daily saline or similar dressings to provide a moist wound environment, debridement when necessary, antibiotic therapy if osteomyelitis or cellulitis is present, optimal control of blood glucose, and evaluation and correction of peripheral arterial insufficiency.

There are two main steps in the medical management of the diabetic foot’:

Care of the wound Debridement of the wound Control of blood sugar and antibiotic therapy

CARE OF WOUND:

Wound coverage by cultured human cells or heterogeneic dressings/grafts, application of recombinant growth factors, and hyperbaric oxygen treatments also may be beneficial at times.

Intractable, infected, cavity wounds sometimes improve with hydrotherapy using saline pulse lavage under pressure (PulsEvac).

Clean but non healing deep cavity wounds may respond to repeated treatments by application of negative pressure under an occlusive wound dressing (vacuum-assisted closure [VAC]).

Hyperbaric oxygen therapy is used rarely and is certainly not a substitute for revascularization.

Charcot foot is treated initially with immobilization using special shoes or braces but eventually may require podiatric surgery such as ostectomy and arthrodesis. If neglected, ulceration may occur at pressure points, particularly the medial aspect of the navicular bone and the inferior aspect of the cuboid

bone. The various dressing materials used in wound dressing of a diabetic patient.

Category Indications Transparent films — polyurethane film with adhesive layer; semipermeable

Dry tominimally draining

Foam — polyurethane foam; open cell, absorbent

Moderate, large exudates clean wound surface

Hydrogels — gel, sheet, gauze; 95% water or glycerin

Dry tominimally draining

Hydrocolloids — wafer with adhesion carboxyl methylcellulose; pectin gelatine; impermeable to oxygen

Low to moderate drianage

Collagen dressings — composite pads with collagen component

Low to heavily draining wounds

Antimicrobial dressings — contain componentssilver or iodine in various preparations

Infected or clean wounda to prevent infection

Saline — amorphous hydrogels; skin cleansers

Clean or infected wounds

Enzymes — collagenase, papain- urea, etc. Necrotic or escharotic wounds

DEBRIDEMENT OF THE WOUND

Debridement may be considered one of the most important aspects of diabetic foot ulcer care, along with offloading and infection control. The guidelines recommend debridement of abscessed tissue along with incision and drainage.

Debridement is ‘the removal of necrotic tissue to decrease the risk of infection and to promote wound closure.’

Debridement should remove all necrotic tissue, callus, and foreign bodies down to the level of viable bleeding tissue. Wounds should be thoroughly flushed with sterile saline or a noncytotoxic cleanser following debridement.

Hydrotherapy is not recommended for diabetic patients. Debridement is essential for the removal of nonviable cells and for healing. Peri wound callus must also be removed, as it may contribute to periwound pressure and incomplete wound contraction. Ulcers may also be obscured by the presence of callus.

Vascular status must always be determined prior to sharp surgical debridement. This may be accomplished through techniques described earlier in this manuscript. Determining local perfusion is of particular importance when deriding ulcers on the distal aspect of the foot.

Debridement is contraindicated in patients with significant vascular compromise, without healing potential, or when they are placed at greater risk.

Debridement of dry eschar in the compromised patient may not be necessary. Special considerations include inadequate blood flow, immunosuppressive therapies, poor nutrition, inadequate diabetes control, and high levels of anticoagulants.

Consideration of risk versus benefit must be made in cases where deeper structures, such as tendon, bone, or capsule, may be exposed as a result of debridement. Clean, granulating wounds should not be derided.

Enzymatic debridement may be considered when sharp surgical intervention is not an option.

Enzymatic debridement may be slow and ineffective where thick dry eschar is present. Enzymes will not debride the periwound callus.

Autolytic debridement through accumulation of exudates under occlusion is not recommended in diabetic patients as the pooling of fluid promotes bacterial proliferation, which may place the diabetic patient at increased risk for infection.

CONTROL OF BLOOD SUGAR AND ANTIBIOTIC THERAPY

Blood glucose level should be controlled by use of insulin in the various forms. This is needed to provide good wound healing and tissue regeneration.

In the absence of diabetes, an individual cellular immune response results in prolonged macrophage activity in a moist environment. Increased moisture may promote autolysis without increasing the risk of infection. In persons with diabetes and other individuals with a compromised cellular immune response, pooling of fluid may promote colonization leading to infection.

Limb-threatening diabetic infections are usually polymicrobial involving multiple aerobic and anaerobic infections. Staphylococcus aureus, beta-hemolytic streptococcus, Enterobacteriaceae, Bacteroides fragilis, Peptococcus, and Peptostreptococcus may be cultured from diabetic ulcers. Malodorous wounds are likely to harbour aerobic and anaerobic organisms.

Choice of antimicrobials in the treatment of a limb-threatening diabetic foot ulcer infection should include those with activity against Gram-positive and Gram-negative organisms and provide aerobic and anaerobic coverage.

The patient's overall wound and medical status as well as the patient's medical history determine the choice of oral versus intravenous antibiotics and the need for hospitalization.

Clinicians may not have the luxury of awaiting culture or biopsy results prior to determining antibiotic choice. Treatment may be changed when dictated by the culture result or when the patient is not responding to treatment. Cultures are most reliable when a deep tissue specimen is obtained.

All organisms recovered from deep tissue cultures should be treated as pathogens unless there is evidence to support that the culture was contaminated from another source. Swab cultures usually grow out numerous surface contaminants and may not provide information on the pathogen(s) causing the deep tissue infection. The rapid deterioration of an infected wound in the diabetic patient necessitates immediate action by a clinician to prevent amputation and other complications.

Topical antibiotics and antimicrobials are not indicated for the treatment of a deep tissue or bone infection.

Topical agents may reduce colonization in the wound, thereby reducing the risk of infection. Topical antimicrobials have neither been proven to eradicate an infection nor to be effective in the treatment of an infection. The primary line of therapy for infection is the use of oral or systemic antibiotics. It is the responsibility of the clinician to differentiate between contamination (the presence of organisms in a wound), colonization (the multiplication of organisms), and infection (the presence of greater than 1 x 105 organisms per gram of tissue).

Diagnosis of an infection should be based on clinical findings. Cultures are meant to identify organisms and to assist in treatment of an infection rather than be used to diagnose infection.

Antibiotics are known to be used indiscriminately and without need resulting in an increased probability of developing resistance. The high morbidity and mortality associated with infected diabetic ulcers suggest that the prescription antibiotics may be more appropriate when clinical signs of infection are suspected in a diabetic ulcer than in wounds of other etiologies, with the exception of immunocompromised patients. Treatment consists of appropriate bandages, antibiotics (against staphylococcus, streptococcus and anaerobe strains), debridement and arterial revascularisation.

It is often 500 mg to 1000 mg of flucloxacillin, 1 g of amoxicillin and also metronidazole to tackle the putrid smelling bacteria.

AMPUTATION :

Any discussion of the diabetic foot requires introduction of the concept of function-preserving amputation surgery. Partial and whole foot amputations frequently are necessary as treatment for infection or gangrene. The goal of treatment is the preservation of function, not just the preservation of tissue. Amputation surgery should be the first step in the rehabilitation of the patient. Because most of these individuals are ambulatory, surgical planning should be directed at the creation of a load-bearing terminal end organ that can interface most easily with accommodative footwear, a prosthesis, or a combination of both (ie, prosthosis). The principles that direct construction of a residual limb for weight bearing with a prosthesis should be employed when performing debridement or partial foot amputation.

The major value of partial foot amputation is the potential for the retention of plantar load-bearing tissues, which are uniquely capable of tolerating the forces involved in weight bearing. The soft-tissue envelope should be capable of minimizing these forces. Avoid the use of split-thickness skin grafts in load-bearing areas. Deformity should be avoided as much as possible. Tendo-Achilles lengthening should be used to avoid equinus deformity and increased loading of the residual forefoot in partial foot amputations. Retention of a deformed foot with exposed bony prominence leads only to decreased walking ability and recurrent ulceration.

In Client:

The client is treated with Inj. Humulin N 10 Units Before breskfast and meals. She is also on T. Metformin 1 gm HS. The management done for here is wound debridement. She is now treated with oral antibiotics Inj Amoxicillin 500 mg BD, Inj Amikacin 500mg BD. The wound in the right leg is treated with Ointment silver max and neomin and wet dressing done TDS.

COMPLICATIONS OF DIABETIC FOOT:

IN BOOK IN CLIENTThis will including cellulitis, septic arthritis, abscess and sinus tract formation, osteomyelitis, gangrene, and charcot foot disease with attention to the differential diagnosis of various pathologic findings.

Not in client

PREVENTION OF DIABETIC FOOT:

Follow the healthy eating plan that you and your doctor or dietitian have worked out.

Be active a total of 30 minutes most days. Ask your doctor what activities are best for you.

Take your medicines as directed.

Check your blood glucose every day. Each time you check your blood glucose, write the number in your record book.

Check your feet every day for cuts, blisters, sores, swelling, redness, or sore toenails.

Brush and floss your teeth every day.

Control your blood pressure and cholesterol.

Don’t smoke.

Care of feet:

Wash your feet in warm water every day. Make sure the water is not too hot by testing the temperature with your elbow. Do not soak your feet. Dry your feet well, especially between your toes.

Look at your feet every day to check for cuts, sores, blisters, redness, calluses, or other problems. Checking every day is even more important if you have nerve damage or poor blood flow. If you cannot bend over or pull your feet up to check them, use a mirror. If you cannot see well, ask someone else to check your feet.

If your skin is dry, rub lotion on your feet after you wash and dry them. Do not put lotion between your toes.

File corns and calluses gently with an emery board or pumice stone. Do this after your bath or shower.

Cut your toenails once a week or when needed. Cut toenails when they are soft from washing. Cut them to the shape of the toe and not too short. File the edges with an emery board.

Always wear slippers or shoes to protect your feet from injuries.

Always wear slippers or shoes to protect your feet.

Always wear socks or stockings to avoid blisters. Do not wear socks or knee-high stockings that are too tight below your knee.

Wear shoes that fit well. Shop for shoes at the end of the day when your feet are bigger. Break in shoes slowly. Wear them 1 to 2 hours each day for the first few weeks.

Before putting your shoes on, feel the insides to make sure they have no sharp edges or objects that might injure your feet.

Guidelines to foot care:

Protect your feet using the guidelines below.

Check your feet. Look at the tops and bottoms of your feet at the end of each day to make sure you have no reddened areas, cuts, or scrapes that could become infected.

Bathing and drying:

* Use warm (not hot) water to wash your feet. Then dry your feet carefully, especially between the toes. Apply cream or lotion after your feet are dry to keep the skin soft and free of dry skin.* If your feet sweat a lot, keep them dry by dusting with talcum powder.

Treating corns and calluses:

* Tell your doctor right away if you develop a corn or callus.* Don't treat corns or calluses yourself. Ask your doctor about using over-the-counter products for these problems.

Toenail care:

* Cut your toenails carefully, cut or file your nails straight across and then use an emery board to smooth the sharp corners. Do not cut the sides or the cuticles.* Clean your nails carefully.* If your nails are thick or hard to cut, ask your doctor's office for help.

Foot warmth:

* Wear cotton socks to bed if you need extra warmth for your feet.* Avoid using hot water bottles or electric heaters to warm your feet. Because you may not fully sense hot and cold with your feet, you may burn your feet accidentally and develop an infection.* Avoid putting your feet where they could accidentally be burned; for example, on hot sand at the beach, in hot bath water or whirlpools, or near a fireplace. Use sunscreen on the tops of your feet.

Footwear:

* Take your shoes and socks off at each visit to your provider so that the doctor can easily look at your feet.* Wear shoes at all times, even in your house, at the beach or by a pool.* Wear comfortable shoes that fit well. Change to a different pair of shoes at least once during the day.* Ask your doctor about specially made shoes, especially if you have foot problems.* Avoid wearing new shoes for more than an hour a day until they are thoroughly broken in.* Avoid tight-fighting shoes, socks and hose.* Wear clean socks and change them at least once a day.

In addition to these foot care guidelines, keeping your blood sugar and your blood pressure close to normal helps prevent foot problems.