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DIABETIC FOOTDone by:
DR Fahad AlbedaiwiFamily medicine resident
Defnition
• The Diabetic Foot may be defined as a syndrome in which neuropathy, angiopathy, and infection will lead to tissue breakdown resulting in morbidity and possible amputation ( WHO 1995 )
World wide (2013):
2nd Place among world countries !!!!!
Epidemiology and facts
Epidemiology and facts
• The overall prevalence of diabetic foot complications was 3.3%
• whilst the prevalence of foot ulcer, gangrene, and amputations were 2.05%.
• The prevalence of foot complications increased with age and diabetes duration predominantly amongst the male patients.
• Diabetic foot is more commonly seen among type 2 patients, although it is more prevalent among
type 1 diabetic patients.
PLoS .One 2015 May 6;10(5):e0124446. doi: 10.1371/journal.pone.0124446. eCollection 2015
high risk foot? Long duration and uncontrolled D.M …Plus one or more:• Peripheral neuropathy• Peripheral vascular disease• Trauma • Previous ulcers• Diabetic nephropathy or retinopathy• Obesity• Lack of education• Male gender ??!!
FOOT AT RISK
Pathophysiology • The critical triad of :1- Neuropathy2- Foot deformity &3- Trauma ……………
will lead to ulcer
The presentation in the majority of pts is an infected ulcer!!
Neuropathy• Sensory : lack of protective sensation
(unrecognized trauma)
• Motor : Change in foot anatomy (Pressure points) & altered gait and deformity
• Autonomic : Lack of sweat ( dry & cracked skin )
Stages Of Ulcer Development
Assessment
• History• Physical examinations• Investigations• Patient• Limb or foot• Wound
Assessment………..History
• Generally: fever, chills, sweats, vom…• Condition : confused, depressed….• Socially : neglected, lack of home sup.• Neuropathy : Numbness, loss of sens. burning, tingling, numbness & nocturnal leg
pains. • Others : duration, diabetic control, previous
ulceration, smoking, HTN....
Assessment………Clinical Ex.What to look for ?• V.S : tachycardia, hypotension…• Signs of volume depletion• Cognitive state:delirium,stupor, coma• Limb-Foot: 1- Biomechnics: deformities, change pressure points2- Vascular status ( arterial, venous, ABI, ischemia, gangrene…3- Neuropathy ( light touch, vibration, monofilament pressure 4- Examining the feet for structural abnormalities such as nails, calluses,
hammer toes, claw toes and flat foot 5-other : tenia pedis , infection , change in color , hygiene .
Diabetic Foot Examination • D deformity• I infection• A atrophic nails• B breakdown of skin• E oedema• T temperature• I ischemia • C callosities• S skin colour
Neurologic assessment Temperature Vibration Sense Pressure Sense Light Touch Proprioception (Romberg’s Sign) Superficial Pain Reflexes
• The monofilament should be placed against intact skin (without callus) and allowed to buckle.
• The patient should have his or her eyes closed during testing and be given a forced choice i.e. asked “ Do you feel the pressure at time A or time B?”
Monofilament Test:
Testing 10 sites (plantar to toes and metatarsal heads 1, 3 and 5, plantar midfoot medial and lateral and planter heal , 1st web space
• The person who cannot feel at least 7 of 10 pedal sites tested is considered to have an absent protective threshold.
Ulcer assessment
1. Site, size and shape2. Edges3. Establish its depth and involvement of deep structures4. Examine it for purulent exudates, necrosis, sinus tracts, and
odor5. Assess the surrounding tissue for signs of edema, cellulitis,
abscess, and fluctuation6. Perform a vascular evaluation. 7. The ability to gently probe through the ulcer to bone has been
shown to be highly predictive of osteomyelitis.8. Establish the ulcer's etiology9. Exclude systemic infection
Classification of diabetic foot ulcerWagner Grading System• Grade 0 skin intact but "foot at risk"• Grade 1: Superficial Diabetic Ulcer & localised• Grade 2: Deep ulcer & extension
– Involves ligament, tendon, joint capsule or fascia– No abscess or Osteomyelitis
• Grade 3: Deep ulcer with abscess or Osteomyelitis• Grade 4: Gangrene to portion of forefoot• Grade 5: Extensive gangrene of entire foot
Classification of diabetic foot ulcer
Neuropathic foot ulcer.
Khanolkar M et al. QJM 2008;101:685-695
©The Author 2008. Published by Oxford University Press on behalf of the Association of Physicians. All rights reserved. For Permissions, please email:
The Charcot foot.
Khanolkar M et al. QJM 2008;101:685-695
©The Author 2008. Published by Oxford University Press on behalf of the Association of Physicians. All rights reserved. For Permissions, please email:
Effects of Diabetic Peripheral Neuropathy
Vascular assessment
• History • Changes in skin• Pulses• Exercise Testing• ABPI• Duplex• Angiography
Ischaemic foot ulcer.
Khanolkar M et al. QJM 2008;101:685-695
©The Author 2008. Published by Oxford University Press on behalf of the Association of Physicians. All rights reserved. For Permissions, please email:
Assessment…….Infection
Infection is diagnosed clinically by • The presence of purulent secretionOR• At least 2 of the cardinal local manifestations
of inflamation• Hotness• Redness• Swelling• Function loss or pain
Classification of diabetic foot infection
• Minimal inflammation with no pus = 1• 2 or more signs or ~2cm erythema around the
ulcer or superficial path. and no systemic manifistations = 2
• As above plus deeper infection, lymphangitis ,abscess or gangrene =3
• As above with systemic or metabolic instability = 4
Classification of diabetic foot infection
Non-Limb-threatening Infections :
Classification of diabetic foot infection
Limb-threatening Infection:
Summary of ulcer
Investigations
• Bloodwork for high BS, DKA, hyperosmolar state…..• Gram staining and culture• Imaging- Plain X-ray- MRI ?- Doppler – Angiogram- US? For deep abscess- Doppler and ABI
Prevention
• Early detection of neuropathy• Educate patient about- Optimizing glycemic control- Using appropriate footwear- Avoid foot trauma- Perform daily self examination- Smoking cessation
• Refer patient with critical ischemia
Five cornerstones of management of the diabetic foot
The situation can be changed & possiblyreduce amputation rates between 50% -85%
by:1- Regular inspection and examination of the foot and patient
education2- Identification of the foot at risk.3- Education of patient, family and healthcare providers.4- Appropriate footwear.5- Multidisciplinary approach & treatment of ulcerative and
non-ulcer pathology
Patient education Decreases the chance of occurrence
– Foot hygiene– Daily inspection– Proper footwear– Prompt treatment of new lesions
Must take an active role in their care– Disease management– Routine nail care– Ulcer management
Elective surgery to correct structural deformities before ulcerations occur
A multidisciplinary approach
• Providing : - Debridement, - wound care, - Adequate vascular supply,- Metabolic control, - Antimicrobial treatment and -Relief of pressure (offloading) are essential in the
treatment of foot ulcer.
Approach to foot wound in diabetics
• ……Principles of wound care1- Determine the need for surgeryRanges from debridement to revascularizationDetermine life- or limb-threatening condition ( NF, GG, Ischemia…. )
2- Formulate wound care plan- Daily inspection- Dressing and debridement as needed- Removal of pressure…..
3- Twice- weekly follow up for outpatients4- WBC, ESR, C-RP, culture … are of limited value
Approach to diabetic foot ulcer
According to ulcer stage0 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 2 Deep ulceration exposing tendons or joints : Surgical
debridement, wound care, offloading, culture-specific antibiotics
3 Extensive ulceration or abscess : Debridement or partial amputation, offloading, culture-specific antibiotics
Approach to ischemic diabetic foot
Ischemia Classification A Not ischemic : no treatmentB Ischemia without gangrene: Noninvasive vascular testing, vascular consultation if symptomatic
C Partial (forefoot) gangrene :Vascular consultation and debridementD Complete foot gangrene : Major extremity amputation, vascular consultation
Approach to diabetic foot infection
Antibiotics Empirical antibiotics • Benzylpenicillin or ampicillin – Streptococcus sp. • Oxacillin, nafcillin or 1 st generation cephalosporin (eg. cefazolin) –
Staphylococcus sp. • Quinolone + aminoglycoside (gentamycin) – Pseudomonas sp. • Methicillin-resistant Staphylococcus aureus – vancomycin or cotri-moxazole • Clostridial species are sensitive to a combination of penicillin G and clindamycin Duration of antibiotic treatment * 1-2 weeks course for mild to moderate infections * more than 2 weeks for more serious infections * 6 - 8weeks for osteomyelitis * If all infected bone is removed,a shorter course (1-2 weeks) of antibiotics, as for
soft tissue infection, may be adequate
Offlaoding Remove pressure from the affected site is essential
•How? -Footwear -Specialised
offloading devices
Offlaoding• FootwearGood shoes are integral to good foot health
Key Message
Mission:… Happy Feet
QUSTIONS?
