management Diabetic foot
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This document discusses the epidemiology, pathogenesis, pathology, classification, management, and treatment of diabetic foot. It notes that diabetic foot affects 15% of diabetics globally and can result in high rates of amputation. Management is multi-disciplinary and involves history, examination, investigations, prevention, wound care, offloading, revascularization procedures, and amputation if needed. Good diabetic control and foot care education are essential to preventing and treating diabetic foot complications.
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management Diabetic foot
- 1. By Dr Kabiru Salisu NOHD KANO 8th oct. 2015
- 2. Outline Introduction - Epidemiology - Pathogenesis - Pathology -Classification Management - History - Examination - Investigation - Treatment Conclusion References
- 3. Introduction Diabetic foot, Is a spectrum of pathological entities that affect the foot of a diabetic patient as a result of its complications Diabetic foots are common throughout the world Resulting in high morbidity, mortality and major economic burden
- 4. Management of diabetic foot is multi-disciplinary Diabetic foot ranges from foot at risk to frank gangrene
- 5. Epidemiology Diabetic foot , affect 15% of all diabetic globaally, 15– 20% may require amputation NHS 2005 showed prevalence of Diabetic foot (DF) of 25% among patients with DM in Nigeria DFU account for up to 24% mortality in patients with DM
- 6. Ogbera & Fasanmade et al, reported - 41.5% of DM patients have foot at risk - Type II diabetes account for 98.1% - Mean duration before development of DF is 10.8yrs - Neuropathy was the commonest risk factor 76%
- 7. Pathogenesis Diabetic foot result from either; Peripheral Neuropathy 80 – 90% Peripheral vascular disease 30-40% Neuroischaemic disease Peripheral Neuropathy - Sensory - Motor - Autonomic
- 8. 2- Peripheral vascular disease - Micro or Macro angiopathy
- 9. 3- Neuroischaemic foot; is the commonest
- 10. Pathology The natural history of diabetic foot was studied it was explained by the following stages STAGE 1- Normal foot
- 11. Stage 2 : High risk foot - Duration of diabetes >10yrs - Poor glycemic control - Neuropathy - PVD - Foot deformity, dryness and callousity - Decreased immunity - Previous healed ulceration - Previous amputation - Retinopathy
- 12. Stage 3 : Ulcerated foot Stage 4 : Infected foot Cellulitis Abscess Osteomylitis
- 13. Stage 5 : Necrotic foot Stage 6 : Unsalvageable
- 14. CLASSIFICATION Wagner’s Stage 0 = Foot at risk Stage 1 = Superficial ulcer/blister Stage 2 = Deep ulcers Stage 3 =Deep ulcer with abscess, osteomyelitis, Stage 4 = Fore-foot gangrene Stage 5 = Hind-foot gangrene
- 16. Brodsky Classification Based on depth, ischemia and gangre UMEBESE AND OGBEMUDIA- DFSS which predict salvagability
- 17. History Presentation could be Emergency or Elective - Emergency- Sepsis/ Septicaemia or Shock - DKA or HHS - Elective – Detailed history and examination - Onset and progression - Risk factor (Numbness, Parasthesia, foot deformity, visual difficulties, pain, claudication, rest pain)
- 18. Purulent discharge, bony spicules Dark discoularation Detailed of diabetic onset, care and control Determine other complications of DM Other relevant medical history
- 19. Examination Absence of hair, callosity Temperature; Cold or Warmth Discolouration; Pale, Dark Deformities; Ulcer characteristics; Site, size, shape, etc Discharge; Colour, Odour
- 20. Neurological Examination - Pain - Light Touch - Vibration test - Temperature - Semmes-weinstein monofilament test Vascular Assessment - peripheral pulses - Ankle Brachial index
- 21. Investigations 1- Blood Sugar / long term control - RBS , FBS, Glycated HB 2- Wound Swab, Tissue biopsy for M/C/S 3- Doppler / Duplex USS 4- X- rays
- 22. 5- Angiography 6- other - U,E & Cr - CXR - ECG
- 23. Prevention of DF Good diabetic care Life style modification - stop smoking - weight loss - Avoidance of high fat Protective foot wears
- 24. Foot care Inspect his feet every day& after prolonged walking Avoid walking barefoot any time Avoid wearing shoes without socks Buy shoes of the correct size Avoid wearing new shoes for > 1h per day Change shoe 2-3 times a day Wash and dry feet every day Moisturing oil or cream for dry skin Cut nails straight
- 25. www.smso.net
- 26. Object found in shoes of patient with neuropathy
- 27. TREATMENT Multidisciplinary Medical Good Glycaemic control Control co-morbidities Control infection
- 28. Wagner grade 0 Foot at risk 1- Determine risk factors and treat 2- Observe preventive measures above 3- Prophylactic bypass surgery 4- Osteotomies to correct deformity
- 29. Wagners Grade 1 & 2 Superficial and deep ulcer 1- Debridement - Surgical, Autolytic, larval 2- Dressing Honey, iodine, film, foam, hydrocolloids, hydrogel, alginates 3- prophylactic Antibiotic 4- skin grafting or flap cover
- 31. 4- Pressure offloading Total contact cast Removable total contact splint
- 32. Scotch cast boot is a lightweight, well- padded fiberglass cast, extending from just below the toes to the ankle, and it is worn with a cast sandal
- 33. 5- Therapeutic foot wear
- 34. Others Crutches Walkers Wheelchairs
- 35. Wagners Grade 3 Deep infection, abscess or OM - I & D - Serial surgical debridement - Wound irrigation with antibiotics - Sequestrectomy - Other measures as above
- 36. Wagner grade 4; fore foot gangrene - Conservative amputations - Revascularisation procedures - Two staged Amputation is recommended
- 37. Wagner Grade 5 Gangrene involved major portion of the foot or hind foot No conservative amputation is possible Major amputation should be offered Knee should be preserved as much as possible
- 38. Other indications of amputation in DF - Ischaemic rest pain that cannot be managed by analgesia or revascularisation - A life-threatening foot infection eg gas gangrene - Severe foot destruction by COM - A non-healing ulcer that is accompanied by a higher burden of disease - Malignant transformation of ulcer
- 39. Post Amputation care Most patients develop DFU on the contra- lateral limb within 18 mths of amputation mortality up to 20- 50% within 3yr Multi-specialist foot care team is required Foot care education should be given to the patient Follow up every 1-3month Foot inspection / PVD assessment at every visit All preventive measures should be taken
- 40. CONCLUSION Diabetic foot is a global pandemic with high morbidity, mortality and socioeconomic burden. Poor patient education, poor preventive care and lack of multi- specialist DF care units are the major concern in our community thus, the need to improve our knowledge, specialisation and care of DF.
- 41. References Ogbera AO, Adedokun A, Fasamade OA. The foot at risk in nigerian with diabetes mallitus- The Nigerian snerio. Int J endocranol metab 2005;4:165-173 Boulton AJM, Connor H, Cavanagh PR (Eds), The Foot in Diabetes (3rd edn). Chichester:Wiley, 2000; 131–142 Akinkugbe OO, Akinyanju OO. Final report – National Survey on non-communicable diseases in Nigeria. Federal Ministry of Health. Lagos, 1997; 65-8 Mccollister EC.surgery of the musclocutenous system volume4. churchill-livingstone.chapter 153; p4189 – 4212 Chadwik P, Edmonds M, Mccardle J et al. Best practice Guidelines: wound management in diabetic foot ulcers. Wounds international 2013; p1-23
- 42. Rodriques J & Mitta N. Diabetic foot andgangrene. Department of surgery Goa medical collage India. www.intechopen.com ; p1-144 Ogbera A, Fansanmade O,Ohwovoriolae A. The diabetic in Nigeria: High costs, Low awareness and lack of care. Diabetic Voice 2006; 51(3)30 - 32 Faisal MA. Diabetic foot ppt. www.smso.net Dalasu OO, Salawu FK, Jimoh AO et al. Diabetic foot care: Self reported knowladge and practice among patients attending tertiary hospital in Nigeria. Ghana Med J 2011;45(2)60-62 Katilombos N, Dounis E, Tsopogas P and Tentolouris N. Atlas of diabetic foot. John wiley & sons 2013;p1- 231
Editor's Notes
- Ranges: Glove and stocking neuropathy Ulcers Gangrene
- diabetes podiatrists vascular surgeons, orthopaedic surgeons, infection specialists, orthotists, social workers psychologists physiotherapist
- 15% of Diabetics 25% of DM admissions in Britain, US Diabetic foot ulcers are common and estimated to affect 15% of all diabetic individuals during their lifetime.2 It is now appreciated that 15–20% of patients with such foot ulcers go on to need an amputation. Almost 85% of the amputations are preceded by diabetic foot ulcer Around 10% of people with diabetes in Nigeria suffer lower-limb complications, and the incidence is rising. In 2005, people with diabetes-related foot ulceration made up almost 12% of total hospital admissions
- Neuropathy—as ‘the presence of symptoms and/or signs of peripheral nerve dysfunction in people with diabetes, after exclusion of other causes PERIPHERAL NEUROPATHY Peripheral neuropathy may predispose the foot to ulceration through its effects on the sensory, motor and autonomic nerves: - The loss of protective sensation experienced by patients with sensory neuropathy renders them vulnerable to physical, chemical and thermal trauma - Motor neuropathy can cause foot deformities (such as hammer toes and claw foot), which may result in abnormal pressures over bony prominence Autonomic neuropathy is typically associated with dry skin, which can result in fissures, cracking and callus. Another feature is bounding pulses, which is often misinterpreted as indicating a good circulation Loss of protective sensation is a major component of nearly all DFUs. It is associated with a seven–fold increase in risk of ulceration6. Patients with a loss of sensation will have decreased awareness of pain and other symptoms of ulceration and infection31
- PERIPHERAL ARTERIAL DISEASE People with diabetes are twice as likely to have PAD as those without diabetes32. It is also a key risk factor for lower extremity amputation30. The proportion of patients with an ischaemic component to their DFU is increasing and it is reported to be a contributory factor in the development of DFUs in up to 50% of patients It is important to remember that even in the absence of a poor arterial supply, microangiopathy (small vessel dysfunction) contributes to poor ulcer healing in neuroischaemic DFUs34. Decreased perfusion in the diabetic foot is a complex scenario and is characterised by various factors relating to microvascular dysfunction in addition to PAD DFUs usually result from two or more risk factors occurring together. Intrinsic elements such as neuropathy, PAD and foot deformity (resulting, for example, from neuropathic structural changes), accompanied by an external trauma such as poorly fitting footwear or an injury to the foot can, over time, lead to a DFU7. persistently recurring ischemic rest pain requiring regular adequate analgesia for more than 2 weeks, with an ankle systolic pressure of 50 mmHg or less and/or a toe pressure of 30 mmHg or less; b. ulceration or gangrene of the foot or toes, with an ankle systolic pressure of 50 mmHg or below and/or a toe pressure of 30 mmHg or less. In such patients, it is important to differentiate neuropathic pain from ischemic rest pain
- INTRACELLULAR HYPERGLYCAEMIa with disturbance in Polyol Pathway Nerves, Blood vessels, Lens, Kidneys Accumulation of Sorbitol & Fructose Intracellular Osmolarity Osmotic Injury Iron pump impairment by Sorbitol Schwann cell injury
- Stage 1 : Normal - Not at risk. The patient does not have the risk factors of neuropathy, ischemia, deformity, callus and swelling rendering him/her vulnerable to foot ulcers. Stage 2 : High risk foot – the patient has developed one or more of the risk factors for Stage 3 : Ulcerated foot – the foot has a skin breakdown. This is usually an ulcer, but because some minor injuries such as blisters, splits or grazes have a propensity to become ulcers, they are included in stage 3. Stage 4 : Infected foot – the ulcer has developed infection with the presence of cellulitis. Stage 5 : Necrotic foot – necrosis has supervened. Stage 6 : Unsalvageable – The foot cannot be saved and will need a major amputation.ulceration of the foot.
- Meggitt -Wagner Classification based on depth, osteomyelitis and gangrene Grade Lesion 0 Foot at risk; callosities, retinopathy, cataract,deformity or cellulitis 1 Superficial diabetic ulcer (partial or full thickness) 2 Deep Ulcer with extension to ligament, tendon, joint capsule, or deep fascia without abscess or osteomyelitis 3 Deep ulcer with abscess, osteomyelitis, or joint sepsis 4 Gangrene localized to portion of forefoot or heel 5 Extensive gangrenous involvement of the entire foot
- University of Texas Diabetic Wound Classification; predictive of outcome UMEBESE AND OGBEMUDIA Predicts limb salvageabilit ≤ 11 unsalvageable 21 best prognostic index COLOUR OF FOOT NORMAL 3 DARKER DISCOLOURATION 2 BLACK 1 PERIPHERAL PULSES DP AND PT PALPABLE 4 POSTERIOR TIBIAL ONLY 3 DORSALIS PEDIS ONLY 2 NONE 1 SENSATION NORMAL LIGHT TOUCH AND PIN PRICK 3 DIMINISHED HYPOESTHESIA 2 INSENSIBILITY TO INSENSATE 1 6 worst prognostic index GANGRENE LIMITED TO 1 OR 2 TOES 5 FULL THICKNESS ULCERATION OF DORSAL SKIN 4 ULCER INVOLVEMENT OF >2 TOES OR BALL OF FOOT 3 OPEN PENETRATING ULCER >50% OF SOLE 2 WHOLE FOOT GANGRENE + SUPRAMALLEOLAR 1 NECROTISING CELLULITIS AGE 40 YEARS 3 41- 60 YEARS 2 > 61 YEARS 1 RADIOGRAPH OF FOOT NORMAL 3 COM OR CALCIFIED PERIPHERAL VESSELS 2 COM + CPV 1
- Brodsky Depth-Ischemia Classification of Diabetic Foot Lesions* Depth Classification Definition 0 At-risk foot, no ulceration 1 Superficial ulceration, not infected 2 Deep ulceration exposing tendons or joints 3 Extensive ulceration or abscess Ischemia Classification A Not ischemic B Ischemia without gangrene C Partial (forefoot) gangrene D Complete foot gangrene
- ABI= Normal if 0.91–1.30 =Mild obstruction if 0.70–0.90 =Moderate obstruction if 0.40–0.69 =Severe obstruction if <0.40 =Poorly compressible if >1.30 Neuropathy Loss of sensation of (a) pain (using a disposable pin; this test is carried out only when the skin is intact), (b) light touch (using a cotton wisp), and (c) temperature (using two metal rods, one at a temperature of 4 ◦C and the other at 40 ◦C) on the dorsum of the feet. Typically, in diabetic peripheral neuropathy the sensory deficit is pronounced at the periphery of the extremities (in a ‘glove and stocking distribution’). A zone of hypoesthesia is found between the area of loss of sensation and a more central area of normal sensation. Achilles tendon reflexes may be reduced or absent. Wasting of small muscles of the feet results in toe deformities (claw, hammer, curly toes) and prominent metatarsal heads. Vibration perception is tested using a 128-Hz tuning fork on the dorsal side of the distal phalanx of the great toes. A tuning fork should be placed perpendicular to the foot at a constant pressure. During examination the patient is prevented from seeing where the examiner has placed the tuning fork. Examination Pressure perception is tested with Semmes–Weinstein monofilaments. Many studies have shown that inability to perceive pressure is related to a several-fold increase in the risk for foot ulceration. The filaments are available in large sets with varying levels of force required to bend them. Diabetic neuropathy can be detected using the 5.07 monofilament (this filament bends with the application of a 10-g force). Monofilament should be applied perpendicular to the skin surface and with sufficient force so that it bends or buckles (Figure 1.3). Total duration of skin contact of the filament should be approximately 2 s. During examination the patient is prevented from seeing if and where the examiner applies the filament. The patient is asked to say whether he can feel the pressure applied (yes/no) and in which foot (right/left foot). Examination is repeated twice at the same site and there is at least one ‘sham’ application, in which no filament is applied (a total of three questions per site). The patient has normal protective sensation when the correct answer is given for two out of the three tests and is at risk for ulceration when they are not. The International Consensus on the Diabetic Foot suggested three sites to be tested on both feet: the plantar aspect of the great toe, the first and the fifth metatarsal heads. The filament must be applied at the perimeter and not at an ulcer site, callus, scar or site of necrotic tissue.
- Glycated Hb <7% Good control, >9% poor control
- Insole layers The upper layer is composed of = cross-linked polyethylene foam =the middle layer of polyurethane - the lower layer of cork
- Inspect his or her feet every day, including areas between toes. Inspection of the sole may be accomplished using a mirror. • Let someone else inspect his or her feet in cases where the patient is unable to do it. • Avoid walking barefoot any time, in- or outdoors. • Avoid wearing shoes without socks, even for short periods. • Buy shoes of the correct size. • Avoid wearing new shoes for more than 1 h per day; feet should be inspected after taking off new shoes; in the case of foot irritation the patient should inform the healthcare provider. • Change shoes at noon, and, if possible, again in the evening; this prevents high pressures remaining on the same area of the foot for a prolonged period. • Inspect and palpate the inside of his or her shoes before wearing them. • Wash his or her feet every day, taking care to dry them, especially the web spaces. • Avoid putting his or her feet onto heaters. • Test the water temperature before bathing using his or her elbow; the temperature of the water should be less than 37 ◦C. • Avoid the use of chemical agents or plasters and razors for the removal of corns and calluses; they must be treated by a health care provider. • Cut the nails straight across. • Wear socks with seams inside out, or preferably without any seams at all. Use lubricating oils or creams for dry skin, but not between toes. • Inspect his or her feet after prolonged walking. • Notify his or her healthcare provider at once, if a blister, cut, scratch, sore, redness or black area develops, or if any discharge appears on socks.
- Objects obtained from diabetics shoes
- the use of a total-contact cast resulted in almost 90% of plantar ulcers healing within an average of 6–7 weeks. Scot cast boot This is a lightweight, well-padded fiberglass cast, extending from just below the toes to the ankle, and it is worn with a cast sandal
- 1- Therapeutic half shoe for the treatment of forefoot ulcers 2- Commercially available heel-free 3- Therapeutic footwear for ulcers on the dorsum of the forefoot shoes for the treatment of hind foot ulcers 4-Heel protector ring which keeps the heel suspended and completely off mattress
- Silicone ring used to keep adjacent toes apart
- base on ischaemic index and condition of skin
- DFU on the contralateral limb within 18 months of amputation. The three–year mortality rate after a first amputation is 20–50%107. In a six-year follow-up study, almost 50% of patients developed critical limb