diabetic foot

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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:

journals.permissions@oxfordjournals.org

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:

journals.permissions@oxfordjournals.org

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:

journals.permissions@oxfordjournals.org

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?

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