Why you should wake up and focus on this presentation?
2006 Third National Health Morbidity Survey
a) prevalence rate of diabetes mellitus has been reported to have increased from 8.3% in 1996 to 14.9% in 2006 1
b) prevalence of lower limb amputation among patients with diabetes was 4.3%.
c) Our MBBS exam
General and medical history
Hx presenting foot complain and duration
Duration of diabetes, management, control and complication
Allergy and any medication
Past medical and surgical history
Habits: walks barefoot? Wets feet at work? Wear socks? Walks a lot?
History of foot problems
Daily activity and current diabetic foot status
Deformities and previous surgery?
Neuropathy and ischemic symptoms?
Skin and nail problems?
History of ulcers
Site, size, duration, odour, type of drainage
Precipitating factor, trauma?
Associated infections symptoms
Any hospitalizations and what treatment
Previous trauma or surgery
Features of Charcot joint
General : any sign of inflammation
Local examination : compare both limbs. Check the normal one first
Musculoskeletal status Attitude and posture Orthopaedic deformities Limited joint mobility, muscle strength Tendo-Archilles contractures/equinus/foot drop Gait evaluation Plantar pressure measurement
Skin and nails of foot Skin appearance: color, texture, turgor, quality and dry skin Calluses, heel fissures, cracking of skin Nail appearances Presence of hair Ulceration, gangrene, infection Interdigital lesions, tinea pedis
Vascular status of foot Pulses Capillary refill time Edema Color change Temperature gradient Venous filling time Changes of ischemia
Neurological status of foot Vibration perception Pressure and touch- monofilament 10gm Semmes Weinstein, cotton wool Pain – pin prick Two point discrimination Temperature perception Deep tendon reflexes – ankle and knee Clonus testing, Babinski test and Romberg test
Evaluation of foot wear
Type and condition of shoes and sandals
Shoe wear, pattern of wear, lining wear
Glucometer/ Random Blood Sugar, Fasting blood sugar
UFEME –Ketonuria, CNS
Wound and blood culture and sensitivity
X-rays of foot (AP, Lateral) (to look for soft tissue gas , Charcot jt, fracture, osteomyelitis)
Bone scan and MRI
Doppler , ankle brachial indices (normal value= 1.1. if <0.9, abnormal)
Plantar foot pressure
Diabetic foot ulcer
Neuropathy Peripheral vascular disease Abnormal foot pressure Hyperglycemia Trauma Foot deformity Limited joint mobility Previous ulceration and amputation Poor vision Chronic renal disease Old age Condition of diabetes Neuropathy Peripheral vascular disease Abnormal foot pressure Hyperglycemia Trauma Foot deformity Limited joint mobility Previous ulceration and amputation Poor vision Chronic renal disease Condition of diabetes
mechanical (surgical debridement, high pressure irrigation, wet to dry dressing),
Done following debridement.
Dressing: normal saline and others (e.g: transparent films, foam, hydrocolloids, calcium alginates, gauze pads, collagen dressings)
Ulcer is covered to avoid contamination and trauma.
Choice of dressings or topical agents depends on the health care provider’s experience, type and site of ulcer, costs involved and patient’s preferences
Reduce the pressure to the ulcer.
Thus, reducing the trauma to the ulcer and allowing it to heal.
Total contact casting
Total non-weight bearing
Removable walking braces with rocker bottom soles
Foot casts or boot
Total contact orthoses
Patellar tendon bearing braces
Half shoe or wedge shoes
Healing sandal- surgical shoe with molded plastizote insole
Total contact casting Healing sandal Cast boot
Treatment of infection
Early incision and drainage
Empirical broad-spectrum antibiotic.
Vascular management of ischemia - Vascular supply should be assessed early before surgery intervention
Treat other medical co-morbidities
DM is a multi-organ systemic disease.
Remove structurally deformed foot which my give rise to high pressure areas causing ulcers that do not heal with off loading technique or therapeutic foot wear
Amputation- gangrene and ulcers with osteomyelitis
Includes removal of infected bone or joint e.g:
metatarsal head resection, partial calcanectomy, exostectomy, sesamoidectomy and digital arthroplasty
I & D, debridement, amputation
a) Mild mod infection
- gram +ve
- 1-2 weeks
b) Severe and life threatening
+ve, -ve, enterococci, anaerobic
More than 2 weeks
c) If osteomyelitis and have not been amputated: 2-8 weeks
Hypertrophic osteoarthropathy currently seen primarily in patients with diabetes who have peripheral neuropathy An abnormal vascular inflow producing bony resorption, bony weakening Etiology The traumatic etiology implies fracture or stress fracture without protective sensation->inherent motion applied to a nonimmobilized fracture. Neurotraumatic Neurovascular Hypertropic response
D amned Nuisance - dt pain, gross malformation, recurrent sepsis, severe loss of function
D ead - PVD, trauma, burns, frostbite
D angerous - malignant tumours, potentially lethal sepsis, crush injury
Breakdown of skin flaps
Skin- eczema, ulcer
Muscle- improper use of prosthesis
Nerve- pain & tender
Boon et al. Davidson’s principle and Practice of medicine. 20 th edition, Churchill Livingstone Elsevier 2006. page;844-846.