Diabetic Foot Flashcards
Definition of diabetic foot?
WHO, International Working Group of DF
- Infection, ulceration or destruction of soft tissue
- associated with neurological abnormality
- and variety degree of vascular insufficiency
What are the components in pathophysiology of diabetic foot?
- Vasculopathy
- atherosclerosis of medium-sized vessels below knee - Peripheral neuropathy
- activation of polyol pathway in nerve cells leads to increase intracellular osmolarity, water influx
- demyelination of nerve fibres - Immunopathy
- inefficient skin metabolism (sweat, vascular supply) leads to disturbance in normal flora
- bacterial growth
Clinical features of vasculopathy in diabetic foot?
- acute ischaemic limb
- pain (distal to proximal), pallor, paraesthesia, paralysis, pulseless - intermittent claudication
- pain (muscular, aggravates with walking, relieves with rest) - chronic ischaemic rest pain
- pain (burning, occur when rest, lying, sitting, at night, relieve with hanging leg down, walking) - arterial ulcer
- painful ulcers, pressure areas, deep, punched out regular edges, cold discoloured surrounding tissue - Generally:
- atrophic skin, loss of hair, trophic nail
Clinical features of sensory neuropathy in Diabetic Foot?
- distal to proximal loss
- stocking distribution
- vibration, proprioception-> light touch -> pain, temperature
*symmetrical numbness, superficial burning pain
Clinical features of motor neuropathy in Diabetic Foot?
- damage to innervation of intrinsic foot muscle
- imbalance between flexion and extension leading to:
i. hammer toe
ii. claw toe
iii. mellet toe
iv charcoat joint (Midtarsal>MTP>Ankle)
v. neuropathic ulcer (abnormal pressure points location)
- painless
Epidemiology
- 1/4 has DM in malaysia
- 15% lower extremity ulcer
- 25% mortality from DFU
- T2DM higher than T1DM
Prognosis
60-80% : Heal
10-15% : Active
12-24% : Amputation
CF of autonomic neuropathy in diabetic foot?
Abnormal thermoregulation of skin sweat mehanism:
- dry skin, skin cracks
CF of immunopathy in DF?
Cellulitis
Abscess
Tinea pedis
Classification of DF (Wagner’s)
Wagner’s Classification
0 - Deformity, callus
1 - Superficial ulcer (do not penetrate subcutaneous)
2 - Full thickness ulcer (fat, tendon, joint capsule)
3 - With abscess, NF, OM or joint sepsis
4 - Localised forefoot gangrene (LF amputation, Ray’s amputation)
5 - Mid or hindfoot gangrene (Below knee amputation)
1,2,3 = debridement 4,5 = debridement + amputation
Classification of DF (King’s)
1 - Normal 2 - High Risk 3 - Ulcerated 4 - Cellulitis 5 - Necrotic 6 - Major amoutation above ankle level
- Not according to progression of disease
- For observational (healthcare workers other than doctors in Singapore)
- Easier for primary care use (refer if grade 3,4,5)
Footwear and footcare
1. Dry socks (wet predispose to fungal infx) 2. Proper nailclipping 3. Orthosis (Measures to reduce plantar pressure) 4. Types of footwear - proper or poorly fit 5. Type of foot i. normal: middle pressure point ii. high arch: lateral pressure point iii. flat: medial pressure point 6. Use of gentlesoaps, warm water to wash, moist 7. Wide and roomie toe box
Footcare
- wash check depan blakang cermin
- basuh gentle soap, lap kering
- moisturiser lepas lap
- potong kuku
Footwear
- leather
- wide roamie toe box
- offloading shoes (comfort dalam)
- wear socks, hygeinic
History taking in DF
- Pain
- Swelling
- Pus discharge
- Skin discolouration
- Numbness
- Fever
Diabetic history
- Medication
- Controlled/Uncontrolled
- Referral (nephro, retino, cardio)
- Diabetic cx symptoms
- hypo
- hyper
- macro
- micro - Caretaker
Physical examination (General)
- Sallow facies
- Fistula
- Acanthosis nigrican (Insulin resistance)
- Ketone breath (fruity)
- Cataract
- Oral thrush
- Insulin injection sites
Physical examination (Local)
Vasculopathy
- Dusky, hyperpigmented skin
- Cold
- CRT
- Pulse (PTA)
- Berger’s Test
- ABSI
- Atropic skin
Motor Neuropathy
- Muscle wasting
- Bunion/bunionete
- Claw (common), Mellet, Hammer
- Pes planus (flat)
- Pes cavus (high arch)
- Rockerbottom (Charcoat Foot)
- Gait (antalgic?)
Autonomic Neuropathy
- Skin fissures
- Dry skin
Sensory Neuropathy
- Touch
- Vibration
- Proprioception
Immunopathy
- Paronychia
- Cellulitis
- Tinea pedis
Ankle Brachial Systolic Index (ABSI)
Ankle systolic/Brachial systolic
Atherosclerosis: >1.2
Normal: 0.9-1.2
Claudication: 0.5-0.8
Ischaemia: <0.5
Investigation
- Biochemical
2 Imaging - Vascular
- Neurological
Biochemical investigation
- Fasting blood glucose
- HBA1C
- FBC (Infection)
- ESR (Inflammation)
- C/S
- Renal profile
Vascular investigation
- ABSI with doppler
- Toe pressure measurement
- assess healing potential
- >40mmHg: 80% healing potential
- <20mmHg: 20% healing potential - Transcutaneous oxygen tension
Neurological investigation
- 2 point discrimination
- Monofilament test
- Vibration perception
- on bony prominence
- 120Hz
Harris Mat usage
Pressure point to look for risk of ulceration
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- Control infection
- Ulcer management
- Prevent amputation
- Prevent recurrent ulcer
Principles of management
- Debridement of necrotic tissue
- Wound care
- Reduction of plantar pressurew
- Treatment of infection
- Antibiotic therapy
- Vascular management of ischemia
- Management of comobidity
- Diabetic footcare
Eradicate - antibiotic - wound debridement Wound care Control comorbidities Footcare, Footwear Educate
Debridement of necrotic tissue
- Surgical
- Mechanical
- Enzymatic
- Autolytic
Wound care
- Dressing
- Adjunctive local therapy
- saline
- anti-septics
- topical antibiotics - Hyperbaric oxygen therapy
Types of surgical amputation
Major (ankle joint and below)
- Rays
- Transmetatarsals
- Syme
- Ankle disarticulation
Major amputation (above ankle)
- Above knee amputation
- Below knee amputation
Concerns before amputation
- Level of disease
- Circulation
- Anatomical and biomechanical issue
Common amputation
- Rays
- Transmetatarsal
- Syme’s
- Right ankle disarticulation
- Below knee amputation
