Diabetic foot

Professor [Link] subramaniam

Singapore
 Diabetic foot
• About 25% 0f diabetic admissions are
foot related: economic impact
• Diabetic foot a major cause of
amputation of lower limb & mortality
• Many body systems affected by diabetes
• Therefore primary prevention through
a multidisciplinary team approach
 Diabetic foot
• Definition:
• A spectrum of pathological changes
in the foot resulting from diabetes
affecting the foot singly or together.
• It affects skin ,muscles , nerves, blood
vessels, bones and joints of the foot
• All the structures of the foot affected
 Diabetic foot: gist of talk
• Pathophysiology of diabetic foot
• Neuropathy / neuropathic foot
• Angiopathy
• Infection
• Assessment of the foot
• Effective ways of prevention
• Management of ulcer, infections etc
Amputations for diabetic foot
 Diabetic foot
• Pathogenesis : multifactorial causes
arising from a chronic upset in glucose
metabolism
• 1. macro and micro-angiopathy
• 2. neuropathy
• 3. infection from diminished immunity
• Severity related to the lack of control of
blood sugar levels
 Diabetic neuropathy
• Affects sensory, motor & autonomic
pathways.
• Most foot problems related to loss of
sensation and mechanical alterations.
They place the skin at risk.
Loss of protective sensation: areas of
increased mechanical stress are not
perceived,
may lead to skin breakdown
 Sensory neuropathy
• Can be quantified with Semmes-
Weinstein monofilament (5.07 size).
• 90% perceiving this size : are free of
ulcerations.
• Those unable: are at risk for
neuropathic complications.
 Motor neuropathy
• Characterized by intrinsic muscle
atrophy.
• It results in motor imbalance &
deformity. Claw toes most common
deformity.
• Effect: increased plantar pressure on
MT heads + extrinsic pressure on
dorsum of toes
 Autonomic neuropathy
• ANS responsible for sweat gland control and
thermal regulation.
• ANS dysfunction results in thick, dry, scaly
skin. Affects the normal hyperaemic
response necessary to heal wounds
• Skin fissuring --- risk of bacterial invasion
• Callus formation, pressure necrosis ,
risk of ulceration
 Neuropathic arthropathy
• Charcot’s joint another complication
• Results in fragmentation , destruction &
dislocation of bones of ankle and foot
• Incidence 1-2.5%
• spontaneous or follows trauma. In any
part of foot , common in mid-foot
• Secondary pressure point in sole: ulcer
• Charcot’s foot and ankle--- instability
 Charcot’s foot in diabetes
• mid foot : talonavicular collapse
• Secondary pressure point: silastic insole
• Hind food: subluxation of ankle
• calcaneal # thru heel ulcer
• fore foot: concentric & longitudinal
atrophy of metatarsals, #s
• special shoes , bracing, surgery
 Angiopathy
• Large vessel disease

• Small vessel disease :Microangiopathy

 Diabetic ulcer
• Size and depth of areas of skin breakdown
• Exposed bone and tendons
• Arterial flow should be assessed
• Arterial doppler –absolute toe pressure
• Transcutaneous oxygen
• Wagner classification on ulcer depth
• Newer ones based on depth and ischaemia
• Identify pt at risk, prevent 60-80% ulceration
 Persistent or recurrent
ulceration
• ie. they do not heal. Why?
• Assess for :
persistent mechanical pressure,
infection,
inadequate healing potential,
nutritional status.
• Prevention: ‘mirror mirror under my
feet , tell me tell me,
are my feet alright today?’.
 Diabetic foot infections
• Superficial: in skin & subcutaneous tissue
• Deep: deep to deep fascia
deep abscess in fasciial spaces
• septic arthritis of joints
• osteomyelitis of bones
infected neuropathic ulcer
• Septicaemic complications ; life at risk
• Vigilance to save life
 Assessment of diabetic foot
• Neuropathy: glove & stocking
anaesthesia
• Monofilament testing
• Secondary pressure point from collapse
• Ulcer, dry skin
• Intrinsic weakness, claw toes: pressure
• Neuropathic joint without infection
• Neuropathic joint with infection
 Assessment of diabetic foot
• Angiopathy:
• Clinical : look, feel
• Brachial/ankle index 0.45 or >
• Toe pressure >30mmHg
• Serum albumin >3.5mg/dL
• transcutaneous oxymetry 20-30 mm Hg
• Good prognostic indicators for healing
 Management of diabetic foot
• Prevention
• exercise program
• of ulcer
• of neuropathic foot
• of ischaemia
• of Infection
• amputations
 Prevention of diabetic foot
• Educate patient at risk
• Educate doctor
• Provision of affordable services within
easy reach
• multidiscilpinary team approach
 Exercise for diabetics
• Exercise can lower risk of heart disease
• Begin to be active
• A regular exercise program can :-
• Stabilize blood sugar
• Reduce need for insulin
• Keep weight under control
 Exercise program for diabetics
• Consult doctor
• Physical examination
• Design a safe pleasurable program
• May need a stress test to evaluate heart
and determine best level of exercise
• at least 30 mins or more 3x a week
• poor sensation:- proper foot wear, wide
toe-box, silica gel, low impact exercises
Management of diabetic ulcer
• Acute ulcers heal without any problem
• become chronic for a reason
• -Poor blood supply
• -Lack of sensation
• Infections from diminished immunity
• Manage the cause that prevents healing
• closed dressing vs. open
 Diabetic foot infections
• Cellulitis
• Deep abscess:- examine the instep of
sole for swelling & deep tenderness
• Drainage, planter incision
• Septic arthritis – drain the joint , debride
• Osteomyelitis : remove sequestra
• extensive infections of rays: ray
amputation
 Septicemia complicating
infections in diabetic foot
• occurs without any warning
• Threat to life :- endotoxic shock
• ketoacidosis
• electrolyte imbalance
• Anaerobic infections – gas gangrene
• other gas producing infections
• Vigilance:Resus, general & local treatment
 Summary : diabetic foot
• Common complication
• preventable through patient and doctor
education, exercise , proper footwear
• neuropathy , angiopathy & infection
may occur singly or together
• Identify the problem & the cause /s
treat accordingly