Diabetic foot

Question 1

What complications of diabetes predispose to foot disease?

Answer 1

Neuropathy: sensory, motor and autonomic.

Peripheral vascular disease.

Question 2

How is light touch investigated in the feet (diabetic)?

Answer 2

Monofilament examination: nylon wire is pushed into the foot, 10g of force applied at the moment it bends.
Used to detect peripheral sensory neuropathy, tested on ball of great toe where 50% of ulcers first occur.

Question 3

What is the pathway to foot ulceration?

Answer 3

Sensory neuropathy.
Motor neuropathy.
Limited joint mobility.
Autonomic neuropathy.
Peripheral vascular disease.
Trauma- repeated minor/discrete episode.
Reduced resistance to infection.
Other diabetic complications, e.g. retinopathy.

Question 4

What is motor neuropathy?

Answer 4

Balance of short and long extensors and flexors of the toes required for balance of weight to be correct on the feet.
Clawing of the toes: don’t take weight as they should, increased pressure on ball of great toe, abnormal sensation in arch of foot- arch may be lost, become flat-footed, losing normal pressure distribution in walking.

Question 5

What is autonomic neuropathy?

Answer 5

Reduced sweating in the foot.

Question 6

What are the features of a neuropathic foot?

Answer 6

Numb.
Warm.
Dry.
Palpable foot pulses.
Ulcers at points of high pressure loading (e.g. ball of foot).

Question 7

What are the different forms of foot ulceration?

Answer 7

Neuropathic foot.
Ischaemic foot.
Neuro-ischaemic foot.

Question 8

What are the features of an ischaemic foot?

Answer 8

Cold.
Pulseless.
Ulcers at the foot margins.

Question 9

What are the features of a neuro-ischaemic foot?

Answer 9

Numb.
Cold.
Dry.
Pulseless.
Ulcers at points of high pressure loading and at foot margins.

Question 10

How is the foot of a diabetic patient assessed?

Answer 10

Appearance: deformity? callus? loss of arch? clawing of toes?
Feel: hot/cold? dry?
Foot pulses: dorsals pedis/ posterior tibial pulse.
Neuropathy: vibration sensation, temperature, ankle jerk reflex, fine touch sensation.

Question 11

How is diabetes (and diabetic foot) managed?

Answer 11

Hyperglycaemia treated.
Hypertension treated.
Dyslipidaemia treated.
Stop smoking.
Education.

Question 12

What is the strategy for preventative management of diabetic foot?

Answer 12

Control diabetes.
Inspect feet daily.
Have feet measured when buying shoes.
By shoes with laces and square toe box.
Inspect inside of shoes for foreign objects, attend chiropodist.
Cut nails straight across.
Never walk barefoot.
Care with heat.

Question 13

List members of the MDT needed to treat diabetic foot.

Answer 13

Diabetologist.
Diabetes nurse.
Vascular surgeon.
Orthopaedic surgeon.
Limb fitting centre.
Orthotist.
Chiropodist.

Question 14

How is foot ulceration managed?

Answer 14

Relief of pressure: bed rest (risk of DVT, heel ulceration), redistribution of pressure/total contact cast.
Antibiotics, possibly long term.
Debridement.
Revascularisation: angioplasty, arterial bypass surgery.
Amputation.