3. Background
infection, ulceration or destruction of tissues of the foot associated with neuropathy and/or
peripheral arterial disease of people with diabetes mellitus
80% of amputations are preceeed for a foot ulcer
50% of patients die within 5 years of DFU
70% of patients die within 7 years of amputation
MOH cost for T2DM management in 2011 was RM1.4 billion
6. Assessment - screening
2. Peripheral arterial disease (excluded when)
• ankle brachial index (ABI) - 0.9-1.3
• toe brachial index (TBI) - >0.75
• continous wave doppler (CWD) - presence of triphasic pedal Doppler arterial
wave form (PDAW)
7.
8.
9. Assessment - diagnosis
1. History
• predictors for increased risk of foot ulceration in diabetes are (1) previous
history of ulceration or lower extremity amputations (2) longer duration of
diabetes (3) at least one absent pedal pulse (4) inability to feel a 10-g
monofilament test
2. Physical assessment
• skin changes - atrophy, nail atrophy, diminished pedal hair, prolonged CRT >2s
and reduced skin temperature
• neurological - as above (monofilament test and vibration perception: 5.07/10-
g SWME monofilament)
• vascular - palpation of femoral, popliteal, posterior tibial and dorsalis pedis
artery
10.
11. Assessment - diagnosis
• musculoskeletal - probe-to-bone test is a clinical technique used in diabetic
patients with a foot infection consisting of exploring the wound for palpable
bone with a sterile blunt metal probe. A positive test is defined as palpating a
hard or gritty substance that is presumed to be bone or joint space
12. Assessment - investigation
Conventional
radiography
• look for osteolysis, arterial calcification, gas shadow, malalignment and peri-articular
fragementation. Features of osteomyelitis may not be visualised until 10-21 days
computed
tomography
• no significant advantage over plain radiographs
Magnetic
resonance imaging
• can be considered to diagnose osteomyelitis when it is not detected by plain
radiograph
16. Referral - urgent
ulceration with fever or any signs of sepsis
critical limb ischemia
suspiscion of deep-seated soft tissue or bone infection
gangrene
35. Treatment - ulcer management
• off loading the treatment
strategy
• non-removable off loading
devices are more effective
• eg TCC (total contact cast) or
walkers rendered irremovable
• others off-loading options
include use of assistive devices
• eg crutches, wheelchair, walking
frames, canes
36. Treatment - Post amputation rehab
• goals include
1. musculoskeletal re-conditioning and cardiopulmonary training
2. contralateral limb preservation
3. emotional care
4. minimisation of systemic complications
5. social re-integration
6. setting realistic patient expectations and functional outcome goals
37. Treatment - Post amputation rehab
• outcomes
1. patients with more distal amputation have better long-term functional
outcomes
2. patients with transtibial amputation have better mobility and decreased
wheelchair used compared with patients with transfemoral amputation -
hence better quality of life
3. longer residual limb length helps to optimise a patient’s ability in
ambulation
38. Monitoring and follow-up
• consider :
1. training caregivers in foot assessment for patients who are unable to
check their own feet
2. the overall health of patients and the progression/deteoration of
wound healing in deciding the frequency of follow-up as part of the
treatment plan
39. Charcot Neuroarthropathy (CN)
• CN can be mistaken for cellulitis at an early stage
• pathognomony: multiple particles of bone and soft tissue embedded
in the deep layers of synovium
• key: inflamed foot, profound neuropathy, foot structural
abnormalities, no fever, elevated ESR
• CN vs osteomyelitis on imaging:
1. xray: focal demineralisation, periosteal reaction, cortical destruction
involving multiple joints
2. CT scan has no added value
3. MRI and PET scan is useful however expensive and hard to acquire
