Diabetic Foot Ulcer

Question 1

Definition of Diabetic Foot Syndrome

Answer 1

Diabetic foot syndrome (DFS), as defined by the World Health Organization, is an “ulceration of the foot (distally from the ankle and including the ankle) associated with neuropathy and different grades of ischemia and infection”

Question 2

What is Diabetic foot ulcer?

Answer 2

DFU refers to a breech in the continuity of the skin epithelium involving its fullthickness or beyond, distal to the ankle joints, in a person living with DM

Question 2

Epidemiology of DFU

Answer 2

The annual incidence of diabetic foot ulcer worldwide is between 9.1 to 26.1 million and annual prevalence of 6.3%.
Around 15 to 25% of patients with diabetes mellitus will develop a diabetic foot ulcer during their lifetime.
The overall prevalence of foot ulcers in Africa was 13%.
In Nigeria, the mortality of 21% and amputation of 35.4% with prevalence rates ranging from 11%-32% among hospitalized patients.

At about half a decade ago, amputation rate from DFU in Nigeria was as high as 52%.
DFU is the commonest cause of diabetes-related mortality in Nigeria after hyperglycemicemergencies.

Question 2

Diagnosis of DMFS: Examination

Answer 2

Examination of ulceration
Examination of the feet
Assessment of the possibility of vascular insufficiency
Assessment for the possibility of peripheral neuropathy

Question 2

Diagnosis of DMFS: History

Answer 2

History
History of trauma, puncture wound (with or without shoe gear)
History of change in shoe gear, deformity, either acquired or congenital, history of callus or blister, history of wound care management, offloading

Local signs of infection
Systemic signs of infection

Symptoms of peripheral neuropathy - hypoesthesia, hyperesthesia, paresthesia, Dysesthesia, radicular pain, anhidrosis

Symptoms of PAD (peripheral arterial disease)- intermittent claudication (cramping), ischaemic pain at rest, nonhealing ulceration of the foot, or frank ischemia of the foot.

Question 2

Risk factors for DFU

Answer 2

• Peripheral neuropathy
• Foot deformity
• Abnormal foot pressure/ inappropriate foot wears
• Previous ulcer/amputation
• Poor gylcaemic control
• Abnormal joint mobility
• Concurrent diabetic complications
• Trauma
• Abnormal joint mobility

Question 2

3 types of DFU

Answer 2

Neuropathic
Neuroischaemic
Ischaemic

Question 3

Wagner-Meggitt Classification of Diabetic Foot

Answer 3

Grade 0 - Foot symptoms like pain, only
• Grade 1 - Superficial ulcers involving skin and subcutaneous tissue
Grade 2 - Deep ulcers involving ligaments, muscles, tendons, etc
Grade 3 - Ulcer with bone involvement
Grade 4 - Forefoot gangrene
• Grade 5 - Full-foot gangrene

Question 4

Differentials of Diabetic Foot

Answer 4

• Basal Cell Carcinoma
• Bites
• Chronic Venous Insufficiency
• Cutaneous B-Cell Lymphoma
• Cutaneous Squamous Cell Carcinoma
• Cutaneous T-Cell Lymphoma
• Kaposi Sarcoma
• Pressure Injuries (Pressure Ulcers) and Wound Care
• Pyoderma Gangrenosum
• Vasculitis and Thrombophlebitis

Question 5

INVESTIGATIONS for DFU?

Answer 5

• Blood tests: FBC, HbA1c, Serum E/U/Cr, ESR, CRP (C-reactive protein)
• Wound biopsy for m/c/s (microscopy, culture, and screen)
• Radiography (soft tissue swelling, foreign bodies, gas bubbles of gas forming organisms, osteomyelitis, stress fractures)
• Ankle-brachial index (Normal ABI averages 1.0 – 1.4. An ABI of 0.8 – 0.9 suggests atherosclerotic disease, with a sensitivity of approximately 95%,ABI below 0.5 suggests a poor chance for healing of distal ischemic ulcerations)
• Pulse-volume recording
• Duplex ultrasonography
• Computed tomography (CT) scanning (cortical erosions, pathologic fracture, and periosteal reactions)
• Magnetic resonance imaging (MRI): osteomyelitis, soft tissue joint space infection (MRI isn’t always necessary)
• Probe to bone test - Using a sterile, solid instrument, the wound should be probed deeply without using force. If there is a rough, coarse feel, this establishes a clinical diagnosis of osteomyelitis. Specificity and sensitivity for the probe to bone test for confirmed osteomyelitis are as high as 0.83 and 0.87, respectively

Question 6

PRINCIPLES OF MGT OF DFS

Answer 6

ADA CONSENSUS STATEMENT
* Multidisciplinary: Endocrinologist, vascular surgeon, orthopaedic surgeon, Dietician, podiatrist, Nurse etc

• Offloading the wound/Bed rest
• Debridement to ensure healthy granulation tissue
• Wound dressings
• Good glycaemic control
• Appropriate use of antibiotics
• Revascularization to correct any peripheral arterial insufficiency
• Limited amputation (prosthesis)
• DVT prophylaxis
• Identify and correct risk factor
• Secondary prevention

Question 7

Maintenance of DFU

Answer 7

Good glycaemic control/ correction of anaemia and other metabolic derangements
Offloading/bedrest
Debridement, DVT prophylaxis
Wound dressing
Appropriate antibiotic therapy
Revascularization
Limited amputation
Patient education

Question 8

PATIENT EDUCATION

Answer 8

The risk of foot ulceration and limb amputation in people with diabetes is lessened by patient education stressing the importance of routine preventive foot care.

Daily self inspection of feet, appropriate shoes, avoidance ofbarefoot walking, avoidance of cigarette smoking, control of hyperlipidemia, and adequate glycemic control.