2. Objectives
• Know what DM and DMFS are
• Understand the pathologic basis for DMFS
• Identify patients-at-risk
• Identify and Evaluate patients with DMFS
• Initiate appropriate treatment, involving the
right personnel.
• Discuss DMFS at Fellowship Exams – P+ grade
3. Diabetes Mellitus (DM)
– A group of metabolic disorders characterized by
Hyperglycemia resulting from defects in Insulin secretion,
or Insulin action, or both
– Chronic condition
• Persistent hyperglycemia
• Type 1
– Defective secretion, Autoimmune
• Type 2
– End organ resistance
– Older patient
– Obesity
– Lifestyle
– 90% of DM
• Gestational DM; Drug induced
5. DM: Diagnostic Criteria
• Blood glucose levels
– Symptoms of diabetes + Casual plasma glucose concentration (PG) ≥200
mg/dl (11.1 mmol/l).
• Casual – done at any time of day without regard to time since last meal.
– FPG ≥126 mg/dl (7.0 mmol/l).
– Fasting - no caloric intake for at least 8 h.
– 2-h postload PG ≥200 mg/dl (11.1 mmol/l) during an OGTT.
• As described by WHO, using a glucose load containing the equivalent of 75 g anhydrous
glucose dissolved in water.
• *HbA1c
– Indicative of glucose level in recent months
– Normal is 4% - 5.6%
– Target in diabetics is 7% or less
• Anomalies of lipid and protein metabolism
6. DM: Complications
• Acute life threatening conditions
– Diabetic Ketoacidosis
– Non-ketotic hyperosmolar syndrome
• Long term complications
– Retinopathy
– Nephropathy
– Peripheral neuropathy
• Foot Ulcers, Amputations, Charcot foot
– Autonomic neuropathy
• GI disorders, Sexual dysfunction, Cardiovascular
– Atherosclerosis
7. DM and the foot
• Foot
– Lowest body part
• Effects of gravity
• Most distant from heart
• Narrow caliber vessels
• Prone to injury
– Scant muscle bulk
– Many bones (and joints)
– Skin of sole is specialized
– Bears weight of entire body (pounds / inch2)
8. Diabetes Mellitus Foot Syndrome
(DMFS)
• DMFS
• Synonym – Diabetic Foot Ulcer (DFU)
• “ulceration of the foot (distally from the ankle and
including the ankle) associated with neuropathy and
different grades of ischemia and infection”. – W H O.
• DM
– 131 million in year 2000
– 366 million by year 2030
– 25% or higher lifetime risk of foot ulcer
• 85% of amputations preceded by ulceration
• 40% of amputation are preventable
11. Evaluation
• History
– DM and treatment
– Ulceration
• Present
• Previous Ulceration & ulcer-like conditions
• Treatment
– Neuropathy / PAD
– Other complications of DM
– Smoking
12. Evaluation
• Examination
– Shoes / Footwear
– Gait
– Deformity
– Skin – breech, loss of hair, dryness, temperature
– Pulsations
• Palpation
• ABI (< 0.91 is suggestive of obstruction)
– Altered sensation
– Motor function
• Investigations
– Aims
– Blood
– Imaging
– Bacteriology
• Risk factors
13. Classification
• Wagner-Meggit
– Depth and Extent of wound
– Simple to use
Grade 0 Intact skin
Grade 1 Superficial ulcer
Grade 2 Deep ulcer – to tendon, bone or joint
Grade 3 Deep ulcer with Abcess or Ostemyelitis
Grade 4 Forefoot gangrene
Grade 5 Whole foot gangrene
14. Treatment of DMFS
• Treat the patient
• Treat DM
• Treat the foot / feet
– Non ulcerated areas are at risk
• Treat the ulcer
– Operative
– Conservative
15. DMFS Treatment
• Pressure offloading
• Debridement and Wound care
• Indications for amputation
• Treatment of Infection
• Counseling
• Long-term patient care
16. DMFS: Management
• Counseling and Education
– Before commencement of treatment
– During treatment
• Documentation
– Including Photography
– Consent
• Multidisciplinary
– Physician
– Nurses
– Physical therapist
– Orthotics and Prosthesis
– Cast technician
– Mental health therapists
– Social / Community health workers
17. DMFS: Summary
• Common complication in patients with DM.
• Spectrum of disorders affecting the soft tissue and
skeleton of the foot and leg.
• A result of neurologic and vascular consequences
of persistent hyperglycemia.
• Treatment is based on careful evaluation of the
patient and classification of the pathology.
• Identification of patients-at-risk and team
approach to management will (hopefully) reduce
individual and social impact of DMFS
