Arterial.8.Diabetic foot Flashcards
Diabetic Foot
One of the serious problems which may affect a diabetic patient & leads to disastrous consequences to the limb or even to the patient’s life.
PREDISPOSING FACTORS of Diabetic Foot
All of them are important but one or more of them may predominate:
- Peripheral neuropathy.
- Vascular affection
- Infection & compromise of the immune system
- Structural deformity
Vascular affection in PREDISPOSING FACTORS of Diabetic Foot
Two factors may impair proper oxygenation and diffusion of nutrients to the tissues:
a. Arterial narrowing by premature atherosclerosis.
b. Microangiopathy & vasculitis
CLINICAL TYPES OF DIABETIC FOOT
- Neuropathic foot :
- Pure ischemic :
- Pure infective :
- The mixed type : Commonest type
Neuropathic foot in CLINICAL TYPES OF DIABETIC FOOT
- Susceptibility to trauma
- Neuropathic affection of intrinsic foot muscles
- Effect of the Bony changes
Susceptibility to trauma in Neuropathic foot in CLINICAL TYPES OF DIABETIC FOOT
- Peripheral neuropathy renders the foot more susceptible to trauma
- as diminished sensation makes the patients unaware of foot injuries
Neuropathic affection of intrinsic foot muscles in Neuropathic foot in CLINICAL TYPES OF DIABETIC FOOT
- allows abnormal movement of the small bones of the foot & joint subluxation
In a normal individual the condition causes an aching pain that Leads the patient to stop walking,
- but in diabetics, they continue on walking leading by time to foot deformities as clawfoot or rocker-bottom foot
Effect of the Bony changes in Neuropathic foot in CLINICAL TYPES OF DIABETIC FOOT
- These bony changes produce localized areas of high pressure & the initial response to high pressure is the formation of a protective callus
- The callus then breaks down resulting in an ulcer
Pure ischemic in CLINICAL TYPES OF DIABETIC FOOT
This is a dry ischaemic gangrene occurring in a diabetic patient with major vascular obstruction.
Pure infective in CLINICAL TYPES OF DIABETIC FOOT
- Pathogenesis
* Morphology
Pathogenesis of Pure infective in CLINICAL TYPES OF DIABETIC FOOT
Diabetic foot infection is polymicrobial.
There is no major vascular affection and all the pulses and sensations are intact.
Morphology of Pure infective in CLINICAL TYPES OF DIABETIC FOOT
Multiple pockets of pus develop and the tissues become necrotic with grey or black sloughs.
The mixed type in CLINICAL TYPES OF DIABETIC FOOT
- Incidence
* Pathogenesis
Incidence of The mixed type in CLINICAL TYPES OF DIABETIC FOOT
Commonest type
Pathogenesis of The mixed type in CLINICAL TYPES OF DIABETIC FOOT
Severe infection in addition to major vascular and neuropathic affection
CLINICAL PICTURE of Diabetic foot
includes CLINICAL TYPES OF DIABETIC FOOT differentiated by :
- site
- size
- depth
- pain
- pedal pulse
Site of Ischemic CLINICAL TYPE OF DIABETIC FOOT
Big toe or at foot margins
Site of neuropathic CLINICAL TYPE OF DIABETIC FOOT
Sites of high mechanical pressure e.g. the heel or the planter surface of metatarsal heads.
Site of infected CLINICAL TYPE OF DIABETIC FOOT
Any site
size of Ischemic CLINICAL TYPE OF DIABETIC FOOT
Small
size of neuropathic CLINICAL TYPE OF DIABETIC FOOT
Large
size of infected CLINICAL TYPE OF DIABETIC FOOT
Large
Depth of Ischemic CLINICAL TYPE OF DIABETIC FOOT
Superficial
Depth of neuropathic CLINICAL TYPE OF DIABETIC FOOT
Deep
Depth of infected CLINICAL TYPE OF DIABETIC FOOT
Superficial ulcer but it extends deep
into the tissues.( undermined edge)
pain of Ischemic CLINICAL TYPE OF DIABETIC FOOT
Painful
pain of neuropathic CLINICAL TYPE OF DIABETIC FOOT
painless
pain of infected CLINICAL TYPE OF DIABETIC FOOT
painful
Pedal pulse of Ischemic CLINICAL TYPE OF DIABETIC FOOT
absent
Pedal pulse of neuropathic CLINICAL TYPE OF DIABETIC FOOT
intact
Pedal pulse of infected CLINICAL TYPE OF DIABETIC FOOT
intact
COMPLICATIONS of DIABETIC FOOT
- Necrotising fasciaitis
- Osteomyelitis of the underlying bone.
- Septicaemia and septic shock may develop if pus is not drained.
Necrotising fasciaitis in COMPLICATIONS of DIABETIC FOOT
- involves fascial spaces & planter tendon sheaths
* leading to spread of infection & gangrene of the foot or even the leg.
INVESTIGATIONS of DIABETIC FOOT
Laboratory
Radiological
Laboratory INVESTIGATIONS of DIABETIC FOOT
- Blood chemistry & CBC.
2. C&S
C&S in Laboratory INVESTIGATIONS of DIABETIC FOOT
It should be obtained deep from the wound as superficial swabs are reliable.
Radiological INVESTIGATIONS of DIABETIC FOOT
- X-ray foot is essential.
2. Angiography is a must in cases of diabetic ischemic foot.
X-ray foot in Radiological INVESTIGATIONS of DIABETIC FOOT
- The reason why it’s essential
* Finding
The reason why X-ray foot is essential in Radiological INVESTIGATIONS of DIABETIC FOOT
to exclude osteomyelitis
Finding of X-ray foot in Radiological INVESTIGATIONS of DIABETIC FOOT
may show gas which indicates severe anaerobic infection
TREATMENT of DIABETIC FOOT
A. Prevention
B. Management
Prevention in TREATMENT of DIABETIC FOOT
- Proper control of diabetes by diet and by medications.
- Avoidance of tight footwear.
- Daily feet care by washing, drying
- Careful trimming of toe nails to avoid their injury
- Avoidance of walking bare footed.
- Early treatment of tinea pedis infection.
Management in TREATMENT of DIABETIC FOOT
- Hospitalization with rest in bed & elevation of the foot.
- Blood sugar is estimated for proper control of diabetes, better by crystalline insulin.
- Early aggressive treatment of infection in diabetic foot
- Drainage of infection & aggressive debridement
Early aggressive treatment of infection in Management in TREATMENT of DIABETIC FOOT
Start with 3rd generation quinolones and clindamycin “Dalacin-C”
Imipenem “Tienam” for severe infections.
Then according to the results of C&S
Drainage of infection & aggressive debridement of diabetic foot
- Drain all pockets of pus
- All necrotic tissue should be excised down to healthy bleeding tissues
- Removal of all infected bone
- Repeated dressings and debridement
- A large raw area is considered for plastic skin coverage in order to shorten the recovery Time
Indication of plastic skin coverage of a large raw area to shorten the recovery time in Drainage of infection & aggressive debridement of diabetic foot
when the wound becomes completely free of infection and contains only viable tissue
In cases of diabetic foot infection & ischemia “Absent pedal pulse”
- Correct ischemia first by balloon Angioplasty
or arterial bypass surgery - then drainage & debridement are done.
