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1362576371 mechanism foot injury and ulcer formation

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mechanism foot injury and ulcer formation

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1362576371 mechanism foot injury and ulcer formation

  1. 1. Overview of Mechanisms causing Diabetic Foot Ulcers Arun Bal Raheja Hospital, Mumbai
  2. 2. Fig Charcot’s Foot with Acute Stage of Destruction
  3. 3. Fig Bilateral Charcot’s Foot in Acute Stage of Destruction
  4. 4. Diabetic Foot Wounds Are Like ICEBERG
  5. 5. How Does Foot Injury Occur ? • Tissue ischemia • Rupture of micro & macro anatomic structures • Irregular interaction between vertical & shear stress ie pressure differentials • Cellular mechanisms • Neuropathy, trauma, infection
  6. 6. Mechanical Factors • Repetitive moderate force as in walking • Inflammation • Erythema and warmth • Collection of exudate • Blister formation • Breakdown of skin ie ulcer
  7. 7. Biomechanical Aspects Of Ulcer Formation and Healing • Structural alteration • Structure & function relationship • Tissue properties • Limited joint mobility • Plantar callus • Fractures
  8. 8. Biomechanical Aspects Of Ulcer Formation and Healing • Weakness of muscles • Prior ulceration • Shear stress • Body weight • Abnormal posture • Footwear
  9. 9. Biomechanical Aspect Of Ulcer Formation and Healing • Foot ulceration is mainly a breakdown of skin under pressure beyond the tolerance of skin. • Other factors may vitiate the progress • Often ulcers occur from within out, • Infection is not really the cause of ulcers, but a consequence
  10. 10. Biomechanical Aspect Of Ulcer Formation and Healing • The pressures on foot are evenly distributed on the fore foot lateral longitudinal arch and heel. • Conditions under which the pressures go beyond tolerance are • Faster the gait • Longer the stride • Foot deformities - disturb the even distribution and create areas of abnormal pressures where breakdown occurs
  11. 11. Biomechanical Aspect Of Ulcer Formation and Healing The break down pressure is between • 500 TO 700 kilo Pascals • Healing thus will occur if we reduce the pressure below this level • Deformities cause excessive pressures and callosities. • Callosities in turn raise pressures 30 times more
  12. 12. Vascular Phenomena • Peak plantar pressure generated while walking is 600 kilo Pascals • Systolic blood pressure of 120mm of Hg can be obliterated by 15 kilo Pascals • Capillary pressure by 6 kilo Pascals • Causes delayed recovery from ischemia • Leading to delayed restoration of normal tissue oxygen concentration
  13. 13. Neuropathy and development of ulcer • Sensory Neuropathy leads to Loss of pain, heat and cold sensation, The insensate foot, leads to ignorance of repeated or damaging trauma of Painful foreign bodies, surfaces that are hot or cold, leading to the development of ulcer
  14. 14. Neuropathy and development of ulcer • Motor – Intrinsic small muscle imbalance, foot deformity, abnormal areas of plantar pressures, ulcer • Autonomic neuropathy – combines tissue ischemia and gross deformities
  15. 15. Component causes of foot ulcers • Peripheral neuropathy 78% • Minor trauma 77% • Deformity 63% • Edema 37% • Peripheral ischemia 35% • Callus 30% • Infection 01%
  16. 16. RISK FACTORS DIABETIC NEUROPATHY • MODIFIABLE • Hyperglycemia • Hypertension • Increased cholesterol • Smoking • Alcohol use • NON MODIFIABLE • Old age • Long duration of diabetes • HLA DR 3/4 genotype • Greater height
  17. 17. ETIOLOGY OF DIFFUSE NEUROPATHY • Hyperglycemia • Vasa nervorum closure • Abnormal fatty acid metabolism • Myoinositol deficiency
  18. 18. Tissue properties • Advanced glycated end products cause either ligamental laxity or hardening • This results in deformities like Hallux rigidus, loosing elasticity, becomes susceptible to trauma • Laxity will cause collapse of the arches and raised mid foot pressures • Displacement of metatarsal cushion distally
  19. 19. Other factors • Vibration and position sense is carried by same fibers and lost together, results in altered gait • Foot lands on the walking surface in abnormal or uneven position, pressures get irregularly distributed with high pressure zones leading to ulceration
  20. 20. Psychological Problems Associated With Diabetic Foot On the rise • Depression • Divorce rate • Alcohol abuse • Disruption in social,domestic environment • Negative attitude On decline • Diabetic self care • Psychological adjustment to illness • Social/family support • Self esteem • Quality of life • Satisfaction with treatment
  21. 21. Preventing ulcer formation • Many common sense advise can be given to prevent ulcer formation • Careful clinical examination should reveal conditions of foot predisposing it to the ulceration • That decides what advise is needed
  22. 22. Contraindicated Exercises • Insensate, deformed foot with previous ulceration or present ulcer contraindicates • Treadmill, jogging, Stairmaster • Prolonged, fast and long stride walking
  23. 23. Common Sense Advise • Educate patients to look at their feet, wash daily with warm water, soft soap, dry in the interspaces, cut nails square, • Wide toe box, extra depth shoes • Insole wing pad, enhances ulcer healing rate to 90% • “Always shoe” policy • Socks – keep feet most

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