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Lecture Notes - Endocrinology > Musculoskeletal and dermatological manifestations of Diabetes > Flashcards

Musculoskeletal and dermatological manifestations of Diabetes Flashcards

1
Q

What is the most common dermatological and MSK complication of diabetes

A

Diabetic foot ulcer

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2
Q

What is the lifetime risk of a diabetic foot ulcer

A

up to 25%

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3
Q

How do diabetic foot problems arise

A

secondary to neuropathy and peripheral arterial disease

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4
Q

What is the usual precipitating event for diabetic foot ulcers

A

trauma

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5
Q

How can sensory neuropathy be detected

A

10g monofilament

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6
Q

How is the filament used

A

it is pressed against the plantar aspects of the first ad fifth toes, the first, third and fifth metatarsal heads and the plantar surface of the heel

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7
Q

When should peripheral arterial disease be suspected

A

in patients with intermittent claudication
cool temperature
absence of hair and
presence of foot ulcers

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8
Q

What is the normal ABPI

A

1.0-1.3

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9
Q

How do we calculate ankle-brachial pressure index

A

Measuring the systolic blood pressure in the brachial, posterior tibial and doornails pedis arteries. The highest of four measurements in the ankle and feet is divided by the highest of the brachial measurements

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10
Q

What does an ABPI over 1.3 suggest

A

the presence of calcified vessels which is common in diabetes

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11
Q

How are diabetic foot infections diagnosed

A

At least two of the following: erythema, warmth, swelling, tenderness
Pus coming out of an ulcer site or a nearby sinus tract

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12
Q

What is a mild infection

A

involvement of the skin or superficial subcutaneous tissues
erythema, warmth, swelling, tenderness,
purulence and cellulitis extending for less than 2cm around the ulcer

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13
Q

What is a moderate infection

A

more extensive infection or involvement of deeper tissues
cellulitis extending >2cm around an ulcer, lymphangitic streaking, deep tissue abscess, gangrene (necrosis) or involvement of muscle, tendon, joint or bone

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14
Q

What is a severe infection

A

signs of systemic toxicity or metabolic instability
fever, chills, tachycardia, tachypnoea, hypotension, confusion, vomiting and blood tests showing severe hyperglycaemia, leukocytosis, metabolic acidosis and raised urea and creatinine

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15
Q

What causes gangrene (necrosis)

A

Ischaemia and is classified as wet or dry

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16
Q

What causes ischaemia in wet gangrene

A

septic vasculitis associated with soft tissue infection

Tissues are black, brown or grey, moist and often malodorous

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17
Q

What causes ischaemia in dry gangrene

A

peripheral arterial disease
Tissues are black , hard and mummified
Clear line between necrosis and viable tissue

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18
Q

What do a lot of patients with diabetic foot ulcers also have

A

osteomyelitis

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19
Q

What factors increase the likelihood of osteomyelitis in patients with diabetic foot ulcers

A

Visible bone or the ability to probe to bone
ulcer size >2x2cm
ulcer depth >3mm
Ulcer duration longer than 1-2 weeks

20
Q

What should blood tests include

A 
FBC
U&E
ESR
CRP 
Blood glucose
HbA1c
21
Q

What are often the causative organisms of superficial ulcers

A 
aerobic Gram positive cocci: 
staph aureus 
strep agalaciae
strep pyogenes 
coagulase negative staphylococci
22
Q

What are often the causative organisms of deep, chronic ulcers

A

gram-negative bacilli:
pseudomonoas aureginosa
proteus mirabilis

23
Q

If an ulcer has extensive local inflammation and signs of systemic toxicity, what should be presumed

A

anaerobic organisms as well as pathogens in deep chronic ulcers

24
Q

What imaging must be performed in diabetic foot infections and why

A

Foot radiograph to look for osteomyelitis

25
Q

What should be performed in patients with one or more of the risk factors for osteomyelitis and whose radiographs are indeterminate for osteomyelitis

A

MRI

26
Q

What can be seen in radiograph for chronic osteomyelitis

A 
cortical erosion 
periosteal reaction 
mixed bony lucency 
sclerosis 
sequestra
27
Q

What does MRI identify in osteomyelitis

A

bone marrow oedema
soft tissue inflammation
cortical destruction

28
Q

What does a duplex US allow

A

anatomical localisation of arterial stenoses and assessment of blood flow haemodynamics

29
Q

What is the gold standard of diagnostic evaluation for peripheral arterial disease

A

angiography

30
Q

What does the management of a diabetic foot ulcer include

A 
Attentive wound management and debridement 
antibiotic therapy 
relief of pressure on the ulcer 
revascularisation 
glycaemic control
31
Q

When should prompt surgical debridement occur

A

in the presence of a large area of infected sloughy tissue
infections complicated by abscess
crepitus with gas in the soft tissues on Xray
purplish discolouration of the skin
extensive bone or joint involvement

32
Q

What sort of devices can be used to relieve pressure on the ulcer

A

removable cast walkers
half shoes
total contact casts

33
Q

What are some factors that have been suggested to contribute to the pathogenesis of neuropathic arthropathy

A

peripheral neuropathy and lack of proprioception may result in ligamentous laxity
Autonomic neuropathy results in vasomotor changes
Exaggerated local inflammatory response to trauma

34
Q

How might patients with Charcot arthropathy present

A

a sudden onset of unilateral warmth, redness and oedema over the foot or ankle
slowly progression arthropathy with insidious swelling over months or years, collapse of the arch of the midget and bony prominences and deformities

35
Q

What are some abnormalities that might be seen on a good radiograph

A

Soft tissue swelling
loss of joint space
osteopenia
forefoot: osteolysis of the phalanges, bone resorption, partial or complete disappearance of the metatarsal head
midfoot and hindfoot: osseous fragmentation, sclerosis, new bone formation, subluxation and dislocation

36
Q

What might a radioisotope scan show in Charcot arthropathy

A

Increased uptake in neuropathic arthropathy

37
Q

How is acute onset Charcot arthropathy treated

A

avoidance of weight bearing on the affected joint until oedema and erythema have resolved (minimum of 8 weeks)

38
Q

What is limited joint mobility commonly associated with

A

thickening and waxiness of the skin on the dorsal surface of the fingers

39
Q

What does the prayer sign test help to identify

A

contractures in the metacarpophalangeal proximal and distal interphalangeal joints

40
Q

How can limited joint mobility be treated

A

Tight glycaemic control
physio
stop smoking
injection of corticosteroid into the palmar tendon sheath

41
Q

What is diabetic muscle infarction characterised by

A

an acute or subacute onset of muscle pain, swelling and tenderness, usually in the muscles of the thigh and calf

42
Q

What does a definitive diagnosis of diabetic muscle infarction require

A

biopsy of the affected area of muscle to demonstrate ischaemic encores and exclude infection

43
Q

What are the most common dermatological manifestations of diabetes

A

protracted wound healing and skin ulcerations

44
Q

How does diabetic dermopathy begin

A

erythematous areas that evolve into areas of circular hyper pigmentation

45
Q

Who are more likely to develop diabetic dermopathy

A

elderly men

46
Q

What is a dermatological sign of insulin resistance

A

acanthosis nigricans

47
Q

What is diabetic sclerodactyly characterised by

A

thickening and waxiness of the skin on the doors of the gingers and may be associated with limited joint mobility

Lecture Notes - Endocrinology (40 decks)

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