Diabetic Foot Flashcards

1
Q

What does the term ‘diabetic foot complications’ refer to?

A

Encompasses the conditions of diabetic foot ulcer (i.e., a full-thickness epithelial defect below/distal to the ankle) and diabetic foot infections (i.e., any soft-tissue or bone infection occurring in the diabetic foot, including osteomyelitis).

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2
Q

What are the risk factors for diabetic foot complications?

A
  • History of diabetes mellitus
  • Sensory neuropathy
  • Previous history of foot ulcer
  • Previous history of partial foot (toe) amputation
  • Charcot’s mid-foot deformity
  • Chronic kidney disease
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3
Q

Briefly describe diabetic foot ulcers

A

A full-thickness epithelial defect that has been present for ≥2 weeks. Most occur in the forefoot, the portion of the foot distal to the tarsometatarsal (Lisfranc) joint.

Patients with Charcot’s arthropathy (mid-foot collapse) may develop ulcers in the mid-foot that are associated with structural abnormalities there.

Heel ulcers are often due to decubitus pressure in non-ambulatory patients debilitated by previous stroke.

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4
Q

Whats signs and symptoms would indicate an infection in diabetic foot complications?

A

The presence of fever, chills, malaise, or anorexia is suggestive of an infection.

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5
Q

How can a neuropathic and ischemic foot ulcer be differentiated?

A
  • Neuropathic: warm, dry skin, foot pulses are palpable
  • Ischemic: cool, pale foot with no palpable pulses
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6
Q

What type of arthropathy is the best descrption of a Charcot joint?

A

Neuropathic

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7
Q

What pulses should be assessed in diabetic foot complications?

A
  • Dorsalid pedis
  • Posterior tibial
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8
Q

What investigations should be ordered for diabetic foot complciations?

A
  • FBC
  • Glucose level
  • X-ray
  • Microbial culture
  • Doppler ultrasound
  • Angiography
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9
Q

Why investigate FBC? And what may this show?

A
  • Ordered in all patients with diabetic foot complications. May suggest the presence of an infection; however, test has poor sensitivity.
  • May show leukocytosis with left-shift.
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10
Q

Why investigate blood glucose level? And what may this show?

A
  • Ordered in all patients with diabetic foot complications. Often elevated in the presence of infection.
  • May be elevated.
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11
Q

Why investigate using x-ray? And what may this show?

A
  • Ordered in all patients with diabetic foot complications to screen for osteomyelitis, fractures, joint stability, and other deformities.
  • May show hypolucencies, cortical destruction/osteolysis and/or joint subluxation.
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12
Q

Why investigate using microbial culture? And what may this show?

A
  • If a diabetic foot infection is suspected, soft tissue or bone samples from the base of the wound can be sent for microbiological evaluation. If this is not possible, a deep swab can be taken as it may provide useful information on the choice of antibiotic treatment.
  • Positive for causative organism in infection.
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13
Q

Why investigate using doppler ultrasound? And what may this show?

A
  • Used to assess the peripheral arterial
    circulation and determine the extent of vasculopathy
  • Reduced peripheral arterial circulation
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14
Q

Why investigate using angiography? And what may this show?

A
  • Considered to be the best test for diagnosing peripheral artery disease.
  • Haemodynamically significant (i.e., >50%) stenosis or occlusions between the aorta and the foot (if peripheral artery disease present).
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15
Q

What organisms can commonly cause diabetic foot infections?

A
  • Staphylococcus aureus
  • Beta-hemolytic streptococci
  • Pseudomonas aeruginosa
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16
Q

Briefly describe the treatment for diabetic foot complications

A
  • Wound care
  • MDT care
  • Offloading footwear
  • Dietary advice and supplements
  • Antibiotic therapy
  • Drainage and/ or debridement
17
Q

When would oral antibiotic therapy be appropriate in mild diabetic ulcer infection? And what can commonly be prescribed?

A
  • Mild infection defined as limited erythema ≤2 cm beyond the ulcer border and/or localised swelling, warmth or pain
  • Treat with a suitable oral empirical antibiotic regimen→ flucloxacillin first-line
18
Q

When would oral or IV antibiotic therapy be appropriate in moderate diabetic ulcer infection? And what can commonly be prescribed?

A
  • Moderate: defined as erythema >2 cm beyond the ulcer border or deep soft-tissue infection (e.g., abscess, osteomyelitis)
  • Broad-spectrum, empirical antibiotics
    • Oral: clindamycin or trimethoprim/sulfamethoxazole plus either ciprofloxacin or amoxicillin/clavulanate
    • IV: vancomycin plus a carbapenem; ampicillin/sulbactam or a quinolone and metronidazole
19
Q

When would oral or IV antibiotic therapy be appropriate in severe diabetic ulcer infection? And what can commonly be prescribed?

A
  • Severe: defined as a foot infection that is associated with two or more signs of the systemic inflammatory response syndrome(i.e., temperature >38°C; heart rate >90 bpm; respiratory rate >20 breaths/minute or PaCO₂ <32 mmHg; white blood cell count >12 × 10⁹ cells/L or <4 × 10⁹ cells/L)
  • Broad-spectrum, empirical antibiotics:
    • Vancomycin plus one of three choices: a carbapenem; ampicillin/sulbactam or a quinolone and metronidazole
20
Q

What is the role of drainage and debridement in treating diabetic foot complications?

A

Surgery should be considered in moderate-to-severe infections to drain/debride any ongoing deep soft-tissue infection (e.g., drain an abscess or infected joint space, debride fasciitis/myonecrosis/necrotic bone).

21
Q

What is the role of amputation in treating diabetic foot ulcers?

A
  • Minor amputations (i.e., toe or partial-foot resections) may be performed on areas with irreversible gangrene.
  • Major amputations are generally reserved for two situations:
    • Infection or gangrene that is so extensive that reconstruction either is not possible or will not preserve meaningful function in the affected limb
    • Patients who have very little or no function in the limb
22
Q

What are the complications of diabetic foot complications?

A
  • Delayed wound healing
  • Osteomyelitis
  • Charcot’s arthropathy
23
Q

What differentials should be considered in diabetic foot complications?

A
  • Venous leg ulcer
  • Gout
  • Acute Charcot’s arthropathy
24
Q

How do diabetic foot complications and venous leg ulcer differ?

A
  • Differentiating signs and symptoms: generally occurs in the gaiter area of the leg (i.e., below the knee, above the malleoli), and rarely occurs on the dorsum of the foot. May have surrounding lipodermatosclerosis (i.e., skin thickening and discoloration due to inflammation, scarring, and haemosiderin deposition).
  • Differentiating investigations: ultrasound or venous plethysmography: can confirm venous incompetence, which makes this diagnosis more likely; however, venous leg ulcers can occasionally occur in the setting of a competent superficial venous system.
25
Q

How do diabetic foot complications and gout differ?

A
  • Differentiating signs and symptoms: may be associated with pain, swelling, and erythema in the forefoot, but is not generally adjacent to a foot ulcer. May occur in the setting of previous history of gout.
  • Differentiating investigations: plain x-ray of foot: shows radiographic signs of gout (i.e., joint space narrowing, scattered bony erosions, tophaceous arthritis).
26
Q

How do diabetic foot complications and acute Charcot’s arthropathy differ?

A
  • Differentiating signs and symptoms: may cause pain, erythema, and swelling. May not be associated with a foot ulcer. Generally occurs in the midfoot (i.e., between proximal metatarsals to calcaneus).
  • Differentiating investigations: magnetic resonance imaging of foot shows midfoot subchondral bone marrow edema (subcutaneous tissues are not typically involved).
27
Q

Briefly describe the monitoring of diabtic foot complications in type 1 diabetes

A

Feet checked by a primary healthcare professional at diagnosis and at least once a year thereafter, or sooner if any foot problems arise. They should also be advised to check their own feet on a daily basis.

28
Q

Briefly describe the monitoring of diabetic foot complications in type 2 diabetes

A

Feet checked by a primary healthcare professional at diagnosis and at least once a year thereafter, or sooner if any foot problems arise. They should also be advised to check their own feet on a daily basis.