Diabetes Education Forum 22 nd Jan 08 The Diabetic Foot

1. Diabetes Education Forum 22nd Jan 08 The Diabetic Foot Maria Haley – diabetes specialist podiatrist Monica Sutton – diabetes specialist nurse Nuala Creagh - diabetologist

2. Objectives of Diabetic Foot Education Forum Clinicians should be familiar with • Classification of risk in the diabetic foot • Care pathways according to risk • Risk assessment • The Sheffield foot assessment tool and Care Pathway • Foot Care advice for people with Diabetes • Diabetic foot problems in primary care • referral criteria, initial management, infection • Charcot arthropathy – acute and chronic features

3. Diabetic foot forum 22nd Jan 2008 7.20 Preventative care for the Diabetic Foot: Classification of risk and Care Pathways – Nuala Creagh 7.35 The Sheffield Risk Assessment Tool and Care pathway – Maria Haley 7.55 Foot Care advice for people with Diabetes – Monica Sutton 8.15 Diabetic foot problems in primary care – Nuala Creagh 8.30 Discussion

4. Epidemiology of the diabetic foot • Commonest cause of hospital bed occupancy • Foot ulcers occur in ~ 15% diabetic patients • >1% undergo amputation • Lower limb amputations ↑ x 15 in diabetes • > 50% require amputation of other limb

5. Causes of diabetic foot ulceration • < 15% purely ischaemic • Remainder ~ 50% neuropathic, ~ 50% neuroischaemic • Neuropathy main initiating factor • Associated with trauma and/or deformity • Triad present in 60%

6. Neuropathic foot ulceration • Typically occurs at sites of high pressure • Metatarsal heads, plantar surface of hallux • Apices of toes • Between toes if footwear tight • Heels, especially in inpatients • Preceded by callus • Complicated by infection • May occur at other sites due to injury

7. Clinical Guidelines Type 2 DM – NICE 2004 • At annual review examination of feet should include • Testing of foot sensation using 10g monofilament or vibration • Palpation of foot pulses • Inspection for any foot deformity and footwear • Classify foot risk as • At low current risk • At increased risk • At high risk • Ulcerated foot

8. Classification of risk in the diabetic foot • Low current risk • normal sensation, palpable pulses • Increased risk • neuropathy or absent pulses or other risk factor • High risk • neuropathy or absent pulses • + deformity or skin changes (callus) or previous ulcer • Foot care emergencies and foot ulcers • new ulcer, swelling, discolouration

9. Foot care according to level of risk 1 • Low current risk (normal sensation, palpable pulses) • Agree a management plan including foot care education with each person • Increased risk (neuropathy or absent pulses or other risk factor) • Regular review, 3-6 monthly, by foot protection team • At each review • Inspect feet • Consider need for vascular assessment • Evaluate footwear • Enhance footcare education ie regular podiatry and footcare advice

10. Foot care according to level of risk 2 High risk (neuropathy/absent pulses + deformity or skin changes or previous ulcer) • arrange frequent review 1-3 monthly by foot protection team • Inspect feet • Consider need for vascular assessment • Evaluate and ensure appropriate provision of • Intensified foot care education • Specialist foot wear and insoles • Skin and nail care ie regular podiatry, footcare advice and orthotics referral

11. Foot care according to level of risk 3 Foot care emergencies and foot ulcers(new ulcer, swelling, discolouration) • Refer to multidisciplinary foot team within 24hrs • Expect that team as a minimum to • Investigate and treat vascular insufficiency • Initiate and supervise wound management • Use dressings and debridement as indicated • Use systemic antibiotics for cellulitis or bone infection as indicated • Ensure an effective means of distributing foot pressures including specialist footwear, orthotics and casts

12. Pathways of footcare in Sheffield – primary care • Risk assessment at annual review by practice nurse/GP • If not competent at risk assessment, request training + refer patient to podiatry for risk assessment • Low current risk • Basic footcare advice • refer to podiatry for group education session or if unable to care for own feet • Increased risk • Inspect feet 3 – 6 monthly • Enhance foot care education • Refer podiatry • High risk • as increased risk + refer for assessment for special footwear

14. Diabetic foot problems in primary care • Referral Criteria • Initial management including infection • Charcot Arthropathy • Amputation

15. Foot care emergencies and foot ulcers – ‘refer to foot care team within 24 hours’ • Primary care guidelines for referral to foot clinic • diabetic foot ulcer/necrotic lesion • callus with local infection • nail pathology with ischaemia and infection • suspected Charcot arthropathy • undiagnosed foot problem in At Risk foot • high risk feet for assessment for special footwear • Emergency referral – same day review or admit • Spreading cellulitis, abscess, wet gangrene

16. STH Foot clinics • NGH • Mon am 9am – 1pm • Tues pm podiatry led • Wed am podiatry led • RHH • Tues pm 1.30 – 5pm • Mon am podiatry led • Wed am podiatry led • Thurs am podiatry led

17. Diabetic foot problems in primary care In all cases assess foot • ? history of injury • ? neuropathic, ischaemic, neuroischaemic • For evidence of infection Nb. The combination of infection and ischaemia is dangerous and may cause rapid tissue loss

18. Initial management of diabetic foot ulcers • Definition • Full thickness break in skin below level of malleoli • Start antibiotics if any evidence of infection • Swab foot ulcer base after cleansing • Dressing • Non adherent, avoid adhesive tape in ischaemic feet • Relieve pressure – avoid weight bearing if plantar • Refer diabetic foot clinic within 24 hours

19. Diabetic foot problems - infection • Spectrum from local infection to spreading life-threatening sepsis • Infected ulcer • Yellowy/grey base, discharge, odour • Sinuses/ exposed tendon or bone • Mild cellulitis (<3cm) • Local erythema, warmth, swelling • Severe cellulitis (>3cm)

20. Infecting organisms in diabetic foot infections • Mild cellulitis – usually staphylococci/streptococci • Deep infections/osteomyelitis – often mixed • staphylococci/streptococci • Gram negative bacilli, eg E Coli, Proteus • anaerobes

21. Diabetic foot infections • First line antibiotics in primary care • Augmentin 625mg tds or Flucloxacillin 500mg qds • If penicillin allergic • Clindamycin 300mg qds – most effective but caution in frail/elderly • Clarithromycin 500mg bd • Cephalexin 500mg tds, unless h/o anaphylaxis with penicillin • If deep ulcer/odour, consider metronidazole

22. Diabetic foot infection – important practice points • Complicates ulcers, rapid tissue loss with ischaemia • Low index of suspicion, detect and treat early • Diabetes specialist podiatrists may request prescription of antibiotics in community • Osteomyelitis frequently requires 3 months or more antibiotics • Prolonged antibiotics may also be indicated in critical ischaemia/ deep foot ulcers

23. Diabetic foot infection - Osteomyelitis • Complicates deep ulcers, often associated with cellulitis • Present if bone exposed or can probe to bone • Typical sausage toe appearance • Bony pain and tenderness typical • Usually diagnosed clinically or by serial xrays • Treatment medical unless extensive tissue loss, septic arthritis, abscess

24. Callus • Callus, particularly plantar, hallmark of neuropathic foot • Callus may overly ulcer • If uncomplicated callus, refer urgently to podiatry • If evidence of local infection, start antibiotics and refer to foot clinic

25. Nail pathology • Ingrowing, involuted toe nails – refer podiatry • Antibiotics if local infection • Nail pathology with infection and ischaemia – refer foot clinic • Fungal infection of nails • refer podiatry for debulking • 3/12 course lamisil if spreading, painful, cosmetically unacceptable

26. Diabetic foot problems - blisters • Caused by trauma, usually inadequate footwear/ failure to wear socks • In neuropathic/neuroischaemic feet • Show need to review footwear • May lead to ulceration • Leave intact if no evidence of infection • If associated infection – cloudy fluid/local cellulitis • Cover with dressing • Antibiotics • Refer urgently to foot clinic

27. Non infective causes of red toe/foot • Acute Charcot arthropathy • Ischaemia • Neuroischaemic diabetic foot may not be cold • Erythema more pronounced on dependency • Gout • Fracture • If doubt re diagnosis in at risk foot refer to foot clinic

28. Charcot arthropathy • Destructive arthropathy • Complication of peripheral neuropathy • Results in gross deformity and risk of ulcers • Early immobilisation reduces extent of deformity

29. Charcot arthropathy – acute phase • Presents with redness and swelling foot +/- leg, +/- pain • May be history of minor injury • May follow fracture or surgery • mimics cellulitis, gout, osteomyelitis, DVT

30. Charcot arthropathy - management • High index of suspicion – if red, warm, swollen neuropathic foot • Immobilise –ie no weight bearing + refer next foot clinic • Pamidronate infusion • Continue immobilisation for ~ 6 months • Plaster of Paris, aircast walker

31. Amputation • Major amputation, below knee or above – usually in the critically ischaemic foot • gangrene • severe sepsis or • severe ischaemic rest pain • Neuropathy alone rare cause of major amputation • Severe sepsis and foot unsalvagable • Severely disrupted ankle of Charcot arthropathy

32. Amputation • Minor amputation – of toe(s), transmetatarsal • osteomyelitis complicating neuropathic ulceration • For ischaemic ulceration/gangrene following revascularisation • Autoamputation of dry gangrenous toes may occur

33. To conclude…. Practice points and pitfalls • Neuropathic foot may be symptomless • Need for diabetic foot risk assessment • Neuropathic ulceration • Callus may obscure underlying neuropathic ulcer • Ischaemia • neuroischaemic foot may not be cold • Acute Charcot arthropathy • suspect if warm, swollen neuropathic foot

34. To conclude… Practicepoints and pitfalls 2 • Refer all new diabetic foot ulcers within 24 hours of presentation • Infection • Treat early, low index of suspicion especially if ischaemia • Prolonged courses often necessary • May need to prescribe at request of podiatrists