The diabetic foot in primary care andre sookdar


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The diabetic foot in primary care andre sookdar

  1. 1. The DiabeticFoot inPrimary CareAndre SookdarClass of 2013
  2. 2. Objectives• Epidemiology• Clinical Presentation• Prevention• Management• Insulin Initiation
  3. 3. DefinitionWHO• The foot of a Diabetic Patient that has thepotential risk of pathologic consequencesincluding infection, ulceration and/ordestruction of deep tissues associated withneurologic abnormalities, various degreesof peripheral vascular disease and/ormetabolic complications of diabetes in thelower limb.
  4. 4. DefinitionAny foot pathology that results from Diabetesor its long-term complications(Boulton. 2002). Diabetes, 30 : 36, 2002
  5. 5. Epidemiology• WHO estimates approx 60,000 persons inT&T were diabetic in 2000• Projected increase to 125,000 by 2030• MOH estimates 1 in 5 adults are diabetic;as much as 175,000• 450 children with Type 1 DM• More prevalent in the East Indiancommunity, but 33% of African attendeesof the public health services are bothDiabetic and Hypertensive• Cause for about 25% Hospital Admissions
  6. 6. Epidemiology• More than 450 non traumatic lower limbamputations in 2010• DM foot problems account for 14% ofadmissions, 29% of bed occupancy• 50% of persons who had lower limbamputations develop depression; 20% diewithin 2 years• V Naraynsingh et al - 822 clinic patientswho had amputations between 2000-2004reviewed; 515 (80%) due to DM
  7. 7. Risk Factors• Age• Duration of DM>10yrs• Gender M>W• Poor glycemiccontrol• Social situation andsupport• Obesity• Alcohol• Smoking• Depression orMental illness• Previous Ulcer• Trauma• Retinopathy• Nephropathy• Willful self neglect
  8. 8. PathologyNeuropathy• Sensory: lack of sensation  RepetitiveTrauma• Motor: Changes in Foot anatomy Pressure Points• Autonomic: Lack of sweat  Dry SkinDistended veins  AV ShuntingOsteoarthropathy: Changes in foot structureCharcot’s foot
  9. 9. PathologyCallus: separates dermis  Ulcer FormationInfection: Disruption of skin barrier, warmthand moisturePeripheral Vascular Disease: reduced bloodflow  decreased O2 supply  increasedrisk of infection and poor healing
  10. 10. Diabetic Foot Assessment• History• Examination• Investigations• Risk Assessment
  11. 11. HistoryGeneral Hx• Medical Hx• Surgical Hx• Drug Hx• AllergiesFoot History• PC for Foot• Neuropathic vsIschaemic Pain• Daily activities &use• Foot Care• Callus Formation• Deformities• Prev Surgeries• Skin & Nail
  12. 12. Ulcer History• Site, size, shape, duration, odor, type• Precipitating event or Trauma• Recurrence• Infection• Hospitalization & Treatment• Wound Care• Patient Compliance• Previous Foot Trauma or Surgery• ? Charcot’s Foot
  13. 13. Examination• General Examination• Inspection• Palpation• Neurological Assessment• Footwear Assessment
  14. 14. General Examination• Cardiovascular• Respiratory• Abdominal• Eyes : Visual Acuity, Fundi• Systemic Signs of Infection
  15. 15. Inspection• Skin: dry, fissures, hair loss, dilated veins,ulcers, bullae, fungal infectionsNecrobiosis Lipoidica Diabeticorum,Diabetic Dermopathy
  16. 16. Inspection• Corns and Calluses• Nails: Thickened or Atrophic, Ingrown,Colour of nail bed, Discharge, Fungalinfections• Oedema: poor fitting shoes, impedeshealingIndicator of CV, Renal status, venousinsufficiency, infection, Gout, Trauma,DVT, lymphoedema and many more
  17. 17. Inspection• Deformity: abnormal pressure distribution• Pes Cavus• Fibrofatty padding depletion• Hammer toes• Claw Toes• Hallux Valgus• Charcot Foot• Iatrogenic
  18. 18. Inspection• Colour• Red – Cellulitis, Critical ischaemia,Osteomyelitis, Gout, Burn• Blue – Cardiac Failure, Venous insuffiency• Black – Necrosis, Ischaemia, Emboli,Bruise, Melanoma, Henna, Dye
  19. 19. Palpation• Pulses – Dorsalis Pedis, Posterior TibialPresence of either makes ischaemiaunlikelyIf neither are present  DopplerDependent Rubor  PVD• TemperatureHot  Infection, Charcot, Bony or Softtissue Trauma, Gout, DVTCold  Ischaemia (acute and chronic),Cardiac Failure• Oedema• Crepitus  Gas Gangrene
  20. 20. Neurologic Assessment• Motor Neuropathy• Classically, high medial longitudinal arch prominent metatarsal heads andpressure points over the plantar forefoot• Assess dorsiflexion for foot drop (commonperoneal nerve palsy)• Autonomic Neuropathy• Dry skin, fissures, distended veins• Stocking distribution
  21. 21. Neurologic Assessment• Sensory Neuropathy• Monofilament test buckles @10g• Vibration 128 Hz tuning fork• Temperature• Light Touch• Pain• Eyes closed, non-touch
  22. 22. Footwear Assessment• Examine bothshoes and socks• Length, breadth,depth• Heel height• Lace/strap vs slip-on• Shoe lining• Foreign bodies• Wear and tear• Snug fit, loose ortight?• What other shoesdoes the patientwear?• Sock size, seams,tightness, holes,absorbency?• Cardboard cutouttest
  23. 23. Investigations• Laboratory• Radiological• Vascular• Neurological• Foot Pressures
  24. 24. Laboratory• CBC• RFT• LFT• RBS, HbA1C• Lipid Profile• CRP• Wound Cultures• Blood and Urine Cultures
  25. 25. Radiological• Plain Films• Osteomyelitis• Fractures• Dislocations• Charcot foot• Foreign Body• Gas• CT• Technetium bone scan – early detection• MRI – Soft tissue
  26. 26. Vascular• Doppler; pulses, Ankle Brachial PressureIndex• <1  ischaemia• Patients with arterial calcification elevated systolic pressure, hence thepressure index may be >1 in spite ofischaemia• Investigate Popliteal and Femoral Arteries
  27. 27. Neurological• Neurothesiometer• Varying vibratory stimulus
  28. 28. Foot Pressures• Plantar pressure measurement devices• Ink and paper
  29. 29. Classification• University of Texas Wound ClassificationSystem of Diabetic Foot Ulcers• Wagner• Edmonds
  30. 30. Edmonds Classification• Based on natural progression• Stage 1: Normal or Low Risk Foot• Stage 2: High-Risk Foot• Stage 3: Ulcerated Foot• Stage 4: Infected Foot• Stage 5: Necrotic Foot• Stage 6: Unsalvageable Foot
  31. 31. Edmonds Classification• Stage 1 – The foot is not at riskSensation and pulses goodNo deformities, calluses or swelling• Stage 2 – One or more risk factors forulcerationNeuropathy and Ischaemia are themain risk factorsDeformity, oedema and callus may notlead to ulceration unless one or both of themain risk factors are present
  32. 32. Edmonds Classification• Stage 3 – Skin breakdown occurs usuallyas an ulcer, but injuries such as grazes,bruises and blisters can eventuallybecome ulcers• Stage 4 – Infection can complicate boththe neuropathic and ischaemic foot• Stage 5 – Necrosis can further lead totissue destruction• Stage 6 – The foot cannot be saved
  33. 33. Edmonds ClassificationExceptions to this classification include• Charcot’s foot• Neuropathic fractures• Painful neuropathy
  34. 34. Management• Regular inspection and examination• Multidisciplinary team• Patient education• Assess risk of foot• Non ulcer pathology• Ulcers and related pathology
  35. 35. Patient Education• Optimum Glycemic control• Management of co-morbid conditions• Stop Smoking• Warning signs
  36. 36. Foot Care• Daily Routine and Inspection• Between toes and below foot• Nail Care: trim wet, straight across, properclippers (NO KNIVES)• Skin Care: Moisture, Callus• Footwear: Proper fit, clean• Avoid excessive heat (Radiators, Hotwater, hot pitch)• Avoid OTC Corn/Callus medications• NEVER WALK BAREFOOT
  37. 37. Non Ulcer Pathology• Calluses & Nails – Podiatrist• Skin pathology• Foot deformities – Surgical / Orthopedicconsult
  38. 38. Ulcer Pathology• Treat the Cause(s) and co-morbid factors• Psychosocial Factors• Relief of mechanical pressure and protectulcer from stress• Local Wound Care• Treatment of Infection: Abx (BroadSpectrum, multiple), Drainage,Debridement• Moisture control: Dressings• Outpatient or Inpatient Care
  39. 39. Ulcer Pathology
  40. 40. Ulcer Pathology• Low Threshold for Referral• Stage 3 and above associated with poorcontrol
  41. 41. Conclusion• Diabetic foot is a serious complication• Associated with poor control• Prevention requires vigilance and patienteducation• Treated by a multidisciplinary team
  42. 42. Thank You• Questions?
  43. 43. References1. Edmonds ME, Foster AVM, Sanders LJ.A Practical Manual of Diabetic Foot Care2nd Ed. Blackwell Publishing 20082. Radwan M. The Diabetic Foot: AnOverview [Internet] cited 1st June 2012Available National Institute of Health. Feet can lasta Lifetime NIH and CDC. 2010