Diabetic foot

Question 1

What are the inspection stages of the diabetic foot examination?

Answer 1

Trophic changes - wasting, hypertrophy etc
Colour - look for pallor (ischaemia) or erythema (cellulitis)
Pressure points - look for arterial ulcers, venous ulcers and neuropathic ulcers
Foot deformities caused by neuropathy e.g. high arches, clawed toes, prominent metatarsal heads
Calluses could indicate incorrectly fitting shoes

Question 2

What are the palpation stages of the diabetic foot examination?

Answer 2

Temperature
Capillary refill
Peripheral pulses

Question 3

How is sensation tested in a diabetic foot examination?

Answer 3

Use a 10g monofilament to assess light touch
Test metatarsal heads
Use 128hz tuning fork to test vibration sense
Use cotton wool to assess touch in glove and stocking distribution

Question 4

How would you complete a diabetic foot examination?

Answer 4

Examine patients gait and footwear for wear inside shoes
Full neurovascular examination of limbs
Check capillary glucose

Question 5

How do you differentiate between ischaemia and neuropathy

Answer 5

Critical toes and absent foot pulses is ischaemia

Neuropathy is injury or infection over pressure points

Question 6

How are at risk feet managed?

Answer 6

Conservative management, lifestyle factors, education on monitoring feet and foot care, regular sessions with podiatrist

Question 7

Where do neuropathic ulcers appear?

Answer 7

In the same place as arterial ulcers

Question 8

How should ulcers be managed?

Answer 8

Should be swabbed for any infection
Should do ABPI for any vascular disease
Optimise diabetic control
Diuretics for any oedema
Regular debridement of callus and dead tissue
Dressing should be applied and changed regularly
Therapeutic footwear

Question 9

How do you manage infection in diabetic foot?

Answer 9

If cellulitis then admit for IV antibiotics, start empirically with benzylpenicillin and flucloxacillin with potentially metronidazole.
IV insulin may improve healing
Get surgical help early
X ray if osteomyelitis suspected

Question 10

How do you manage charcot foot?

Answer 10

Bed rest with cast and local warmth, bisphosphonates can help
optimisation of diabetic control, including BP and lipids, as well as specialised footwear