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THE DIABETIC FOOT

THE DIABETIC FOOT. Definition. “Infection, ulceration and/or destruction of deep tissues associated with neurological abnormalities and various degrees of peripheral vascular disease in the lower limb” in the diabetic subject. (WHO, 1985). Impact.

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THE DIABETIC FOOT

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  1. THE DIABETIC FOOT

  2. Definition “Infection, ulceration and/or destruction of deep tissues associated with neurological abnormalities and various degrees of peripheral vascular disease in the lower limb” in the diabetic subject. (WHO, 1985)

  3. Impact Increased morbidity- 15% of DM patients will develop DFU Increased mortality Increased bed occupancy- DF problems account for 50% of DM related admissions.

  4. clinical Evaluation history of illness- duration of illness, glycemic control, other complications, current treament, presence/absence of constitutional system. EVALUATION OF ULCER: Origin of ulcer, neuropathic, ischaemic or neuro-ischaemic the site, size, depth, margin, and base of ulcer presence of odour, exudates or bleeding.

  5. DIABETIC FOOT EXAMINATION Right side of patient greet, introduction, consent exposure of both legs. inspection- look at both legs-, pigmentary changes, edema, cyanosis, cellulitis, ulcers (site, size, edges, depth, floor,margin, surrounding skin, odour, exudates and bleeding) muscle wasting, joint deformities, amputations. inspect the web spaces

  6. palpation- differential warmth, tenderness, peripheral pulses- dorsalis pedis, posterior tibial and femoral arteries. venous filling time. sensations - light pressure using Semmes-Weinstein 10G monofilament -light touch using cotton wool (in levels or non dermatomal pattern/socks and gloves)

  7. temperature perception- hot and cold joint position sense- on the big toe vibration sense- tunning forks deep tendon reflexes- ankle, patellar evaluation of gait Assessment of footwear- types of shoes, fitting, wear patterns, insole and foreign bodies. cover the patient thank the patient

  8. Types Neuropathic foot Ischaemic foot Neuro-ischaemic foot (The purely ischaemic foot with no concomitant neuropathy rarely exists)

  9. The neuropathic foot Usually warm, and well perfused Bounding feet pulses due to arterio-venous shunting Distended dorsal veins Usually dry from diminished sweating Prone to fissuring Callus formation-dry and hard

  10. The neuropathic foot (contd) Arch of the foot may be raised Toes may be clawed Prone to bone and joint disorders e.g Charcot joint Necrosis devlops Ulcers develop on the sole of the foot (all due to increased planter pressures)

  11. The Neuro-ischaemic foot Foot usually cool, usually pulseless with poor perfusion Typical claudication may be absent because of neuropathy If severely infected the foot may be warm Heavy callus does not usually develop – requires good blood flow

  12. The Neuro-ischaemic foot –contd. Ulcers usually located on the margins, tips of toes and back of the heel Usually caused by trauma and unsuitable foot wears

  13. Staging of diabetic foot WAGENER STAGING - Popular but only involves staging of mainly ULCERS but not the foot

  14. Wagener Staging of diabetic foot ulcers (based on depth of ulcer) Grade 0: No ulcer in a high risk foot Grade 1: Superficial ulcer –full skin thickness, no underlying tissues involved Grade 2: Deeper ulcer down to ligaments and muscle but no bone involvement or abscess formation Grade 3: Deep ulcer with cellulites or abscess + - osteomyelitis

  15. Wagener Staging -contd Grade 4: Localized gangrene. involvement of the extremities (forefoot gangrene) Grade 5: Extensive gangrene involving the whole foot

  16. Risk factors for foot ulcer Peripheral Neuropathy sensory, motor and autonomic • Peripheral vascular disease • Previous history/evidence of foot lesions: ulceration, scars, deformity or amputation • Poor foot care • Age and duration of DM

  17. Diabetic Foot Triad TRAUMA NEUROPATHYINFECTION ISCHAEMIA

  18. INVESTIGATIONS LABORATORY INVESTIGATIONS FBC+ESR, BLOOD CULTURE FBS, HBA1C URINALYSIS, S/E/U/Cr WOUND SWAB FOR C/S TISSUE BIOPSY

  19. Doppler US, Ankle brachial index (ABI) {Normal 0.9-1.2; Definite vascular disease 0.6-0.9;Severe Less than 0.6 X-RAY : Soft tissue swelling, foreign bodies, calcified vessels, gas bubbles, osteomyelitis, stress fractures, and ospteopenia. duplex ultrasonography, impedance plethysmography, Radionuclide Bone Scan, WBC Scintigraphy, Pedography. invasive arterial procedures- Arteriography -GOLD STANDARD

  20. PRINCIPLES OF MANAGEMENT OF DIABETIC FOOT ULCERS Relief of pressure removal of Necrotic tissues treatment of infections wound care / dressing restoration of skin perfusion improving metabolic control treatment of co-morbidities psycho-social support and patient education

  21. relief of pressure: involves avoiding of all mechanical stress on the wound. involves use of; total contact casts (gold standard), surgical shoes, healing sandals/ half shoes, bedrest, clutches, wheel chairs type depends on location of wound and patients level of activity. removal of necrotic tissue: surgical (sharp debridment) enzymatic ( addition of exogenous proteolytic enzymes to the wound surface. e.g collagenases and papain-urea combinations.

  22. autolytic - digestion of necrotic tissue by phagocytic activity of macrophages and endogenous proteolytic activity, this is enhanced by use of occlusive, semi-occlusive and interactive dressings, mechanical- use of wet -to-dry dressings to unselectively remove tissue both normal and necrotic. others include wound irrigation. Biosurgery: use of larvae of green bottle fly (Lucilia sericata) to debride sloughy tissues selectively . they dont attack healthy tissue or burrow under skin.

  23. treatment of infections wound infections in DFU are usually polymicrobial with gram+, gram- aerobes and anaerobes. commonest- gram positive aerobes :1st (50-75%)-staphylococcus aureus, 2nd- staph. epidermidis. commonest anaerobes- Bacteroides fragilis less common are gram negative aerobes like Psuedomonas aureginosa

  24. antibiotic combinations: commonly involves Metronidazole 3rd generation cephalosporns or Quinolones flucloxacillin given either IV or Orally: depending on stage of the infection and presence of complications

  25. wound care antiseptics - EUSOL A and B, hydrogen peroxide Honey- high osmolality inhibit mocrobe growth, releases H2O2, antibacterial activity, stimulate lymphocyte and phagocytic activity. other measures: bioengineered epidermis and dermis, hyperbaric oxygen treatment, vacuum assisted closures

  26. restoration of skin perfusion by revascularisation surgeries optimal glycemic control using S.C Insulin treatment of comorbidities like - hypertension,hyperlipidemia, anaemia psychological support- TLC: depression from loss of productivity, hospitalisation, reduced quality of life, threat of possible limb loss.

  27. patient education check feet daily wash and dry feet daily avoid extremely hot or cold bathe thin coat of lubricating oil or cream on skin but not between toes. cut nails straight across properly fittins stockings changed daily check inside of your shoes, buy comfortable shoes(in the afternoon). protect your feet and see care provider for foot exam regularly

  28. Don'ts walk bare foot walk on hot surfaces, sandy beaches, road wear sandals with thongs inbetween wear pointy-toe shoes, high heels, stilettos, strapless or backless shoes. smoke put jewelries on your feet

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