Diabetic Foot

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Diabetic Foot

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Diabetic Foot

  1. 1. <ul><li>Diabetic Foot </li></ul>
  2. 2. Diabetic foot ulceration is due to an interplay of neuropathy, tissue ischaemia (microcirculatory and macrovascular disease) and secondary infection.
  3. 3. APPROACH TO DIABETIC FOOT Diagnosis & evaluation Identification of risk factors History Physical examination Investigations Foot ulcer Threatening infections Charcot’s arthropathy Amputation
  4. 4. A) Diagnosis and evaluation
  5. 5. History General Medical Foot and ulcer
  6. 6. General & medical history Foot history <ul><li>Presenting foot cx & duration </li></ul><ul><li>Duration of diabetes, management and control </li></ul><ul><li>CVS, renal, ophthalmic evaluation & other co morbidities </li></ul><ul><li>Social history – alcohol / tobacco / occupation / dietary habits </li></ul><ul><li>Current medication and antibiotic use </li></ul><ul><li>Allergies </li></ul><ul><li>Past Medical & Surgical history </li></ul><ul><li>Cultural habits – walks barefoot / wets feet at work / wear socks / walks aloof </li></ul><ul><li>Patients’ perception of DM, necessity of weight and diet control </li></ul><ul><li>·Able to afford diabetic drugs </li></ul><ul><li>Daily activity & current foot status </li></ul><ul><li>Footwear – shoes / slippers / sandals / use different footwear / Fit </li></ul><ul><li>Foot-care – aware of foot problem / inspect foot / wash feet / proper nail clipping / attend podiatry </li></ul><ul><li>Callus formation </li></ul><ul><li>Deformities and previous foot surgery </li></ul><ul><li>Neuropathy and ischemic symptoms </li></ul><ul><li>Skin & nail problems – sweaty feet / fungal infections / skin disease / blisters/ Ingrown toenails </li></ul>
  7. 7. Ulcer History <ul><li>Site, size, duration, odour and type of drainage </li></ul><ul><li>Precipitating event or trauma </li></ul><ul><li>Recurrences – number of times </li></ul><ul><li>Associated infections </li></ul><ul><li>Frequency of hospitalizations and treatment given </li></ul><ul><li>Wound care / measures to reduce plantar pressure </li></ul><ul><li>Patient compliance </li></ul><ul><li>Previous foot trauma or surgery </li></ul><ul><li>Features of Charcot’s joint </li></ul>
  8. 8. PHYSICAL EXAMINATION General examination Local examination Signs of inflammation (pyrexia etc) Musculoskeletal status of foot & leg Skin & nails of foot Neurovascular status Patient’s footwear
  9. 9. Musculoskeletal status Skin & nails <ul><li>Attitude and posture of lower extremities and foot </li></ul><ul><li>Orthopedic deformities – Hammertoes / Bunions / Pes planus orcavus / Charcot deformities / amputations / prominent metatarsal heads </li></ul><ul><li>Limited joint mobility – active and passive movements </li></ul><ul><li>Tendo - Achilles contractures / equines / foot drop </li></ul><ul><li>Gait evaluation </li></ul><ul><li>Muscle group strength testing </li></ul><ul><li>Plantar pressure assessment </li></ul><ul><li>Skin appearance: color, texture, turgor, quality, and dry skin </li></ul><ul><li>Calluses, heel fissures, cracking of skin due to reduced sweating inautonomic neuropathy </li></ul><ul><li>Nail appearance: Onychomycosis, dystrophic, atrophy, hypertrophy, paronychia </li></ul><ul><li>Presence of hair </li></ul><ul><li>Ulceration, gangrene, infection </li></ul><ul><li>Interdigital lesions </li></ul><ul><li>Tinea pedis </li></ul>
  10. 10. Neurovascular status <ul><li>Neurological status </li></ul><ul><li>Vibration perception: Tuning fork </li></ul><ul><li>128 Hz </li></ul><ul><li>Pressure & Touch: Cotton wool </li></ul><ul><li>(light) </li></ul><ul><li>Pain: Pinprick, using sharp and </li></ul><ul><li>blunt tool ( e.g. Neurotip) </li></ul><ul><li>Two-point discrimination </li></ul><ul><li>Temperature perception: hot and </li></ul><ul><li>cold </li></ul><ul><li>Deep tendon reflexes: ankle, knee </li></ul><ul><li>Clonus testing </li></ul><ul><li>Babinski test </li></ul><ul><li>Vascular status </li></ul><ul><li>Pulses (dorsalis pedis, posterior </li></ul><ul><li>tibial, popliteal, femoral) </li></ul><ul><li>Presence of edema </li></ul><ul><li>Temperature gradient </li></ul><ul><li>Colour changes: Cyanosis, </li></ul><ul><li>dependent rubor, erythema </li></ul><ul><li>Changes of ischemia: Skin </li></ul><ul><li>atrophy; nail atrophy, abnormal </li></ul><ul><li>wrinkling,diminished pedal hair </li></ul>
  11. 11. Patient’s footwear <ul><li>Type and condition of shoes / sandals </li></ul><ul><li>Fit </li></ul><ul><li>Shoe wear, pattern of wear. lining wear </li></ul><ul><li>Foreign bodies </li></ul><ul><li>Insoles, orthoses </li></ul>
  12. 12. INVESTIGATIONS Biochemical Neurological Plantar foot pressure Vascular Foot imaging
  13. 13. Biochemical <ul><li>RBS </li></ul><ul><li>Hb A1c </li></ul><ul><li>FBC </li></ul><ul><li>BUSE </li></ul><ul><li>ESR </li></ul><ul><li>Wound & blood culture </li></ul><ul><li>Urine FEME </li></ul><ul><li>Urine C&S </li></ul>
  14. 14. Foot imaging <ul><li>Plain radiograph </li></ul><ul><li>Features of OM, osteolysis, fractures, dislocations, medial arterial calcification, soft-tissue gas and Charcot’s joint </li></ul><ul><li>CT scan </li></ul><ul><li>delineate suspected bone or joint pathology not evident on plain radiographs </li></ul><ul><li>Radioisotope Technetium bone scan </li></ul><ul><li>to detect early pathology such as osteomyelitis, fractures and Charcot’s arthropathy </li></ul><ul><li>MRI </li></ul><ul><li>important imaging modality in diabetic patients with foot infections </li></ul><ul><li>allows evaluation of both soft-tissue and bone pathologies </li></ul>
  15. 15. Vascular Ix <ul><li>Indicated to evaluate the extent of occlusive </li></ul><ul><li>vascular disease and in the assessment of healing </li></ul><ul><li>potential </li></ul><ul><li>Doppler segmental artery pressures </li></ul><ul><li>Ankle-brachial indices (ABI) Normal value 1.1, <0.9 abnormal </li></ul><ul><li>Toe pressure measurements </li></ul><ul><li>85%-100% of foot lesions will heal when toe pressures are >40mmHg and less than 10% will heal if<20mmHg </li></ul><ul><li>Transcutaneous oxygen tension (TcPO2) </li></ul><ul><li><10mmHg correlates with non-healing, >30mmHg correlates with healing </li></ul>
  16. 16. Neurological Ix <ul><li>Sensory examination with a 5.07 Semmes- Weinstein monofilament (10gm) wire </li></ul><ul><li>single most practical measure of risk assessment </li></ul><ul><li>cost effective </li></ul>
  17. 17. Ulcer History <ul><li>Site, size, duration presence of discharge </li></ul><ul><li>How it was noticed by patient </li></ul><ul><li>Precipitating event or trauma </li></ul><ul><li>Painful or painless </li></ul><ul><li>Colour </li></ul><ul><li>Gangrenous changes of digits </li></ul><ul><li>Recurrences – number of times </li></ul><ul><li>Associated symptoms </li></ul><ul><li>Complications of ulcer on daily activities </li></ul><ul><li>Frequency of hospitalizations and treatment given </li></ul><ul><li>Wound care / measures to reduce plantar pressure </li></ul><ul><li>Patient compliance </li></ul><ul><li>Previous foot trauma or surgery </li></ul><ul><li>Features of Charcot’s joint </li></ul>
  18. 18. Examination of ulcer <ul><ul><li>Inspection </li></ul></ul><ul><ul><li>Single/multiple </li></ul></ul><ul><ul><li>Site </li></ul></ul><ul><ul><li>Shape </li></ul></ul><ul><ul><li>Size </li></ul></ul><ul><ul><li>Margin: well defined </li></ul></ul><ul><ul><li>Edge: punched-out, sloping, inverted </li></ul></ul><ul><ul><li>Depth: in mm and up to what tissue plane </li></ul></ul><ul><ul><li>Floor: </li></ul></ul><ul><ul><ul><li>granulation tissue, slough tissue, clean </li></ul></ul></ul><ul><ul><ul><li>Pale/pink colour </li></ul></ul></ul><ul><ul><ul><li>Bone, ligament, tendon </li></ul></ul></ul><ul><ul><li>discharge: serous, bloody, purulent </li></ul></ul><ul><ul><li>Skin surrounding the ulcer </li></ul></ul><ul><ul><ul><li>Inflammatory changes: redness, swelling </li></ul></ul></ul>
  19. 19. <ul><li>Palpation </li></ul><ul><ul><li>Temperature: warm/cold </li></ul></ul><ul><ul><li>Tenderness of ulcer and the surrounding skin </li></ul></ul><ul><ul><li>Base of ulcer: </li></ul></ul><ul><ul><ul><li>indurated, fluctuate, fixation (mobility) </li></ul></ul></ul><ul><ul><ul><li>Pus oozing </li></ul></ul></ul><ul><ul><ul><li>Contact bleeding </li></ul></ul></ul><ul><li>Movement </li></ul><ul><ul><li>Toe, ankle </li></ul></ul>
  20. 20. <ul><li>Neurovascular examination </li></ul><ul><ul><li>Peripheral pulses </li></ul></ul><ul><ul><li>Capillary return </li></ul></ul><ul><ul><li>Sensory </li></ul></ul><ul><ul><ul><li>Pin-prick, vibration, proprioception </li></ul></ul></ul><ul><ul><li>Power: foot drop </li></ul></ul><ul><ul><li>Reflex: ankle reflex </li></ul></ul><ul><li>Systemic general examination </li></ul><ul><ul><li>Palpation of inguinal lymph nodes </li></ul></ul>
  21. 21. Approach of Diabetic Foot Infections
  22. 22. Diabetic foot complications <ul><li>Foot or lower-extremity ulcers, occur in ~7% of diabetic individuals each year </li></ul><ul><li>The risk of lower-extremity amputation is increased by a factor of eight </li></ul><ul><li>50,000 lower-extremity amputations performed annually in USA </li></ul><ul><li>~84% preceded by an ulcer </li></ul>
  23. 23. Cornerstone of management <ul><li>Regular inspection and examination </li></ul><ul><li>Identification of the foot at risk </li></ul><ul><li>Education </li></ul><ul><li>Appropriate footwear </li></ul><ul><li>Treatment of non-ulcerative pathology </li></ul>
  24. 24. Management of foot ulcers <ul><li>Look for the cause </li></ul><ul><ul><li> Ill -fitting shoes </li></ul></ul><ul><li>Type </li></ul><ul><ul><li> Neuropathic </li></ul></ul><ul><ul><li> Ischaemic </li></ul></ul><ul><ul><li> Neuro-ischaemic </li></ul></ul>
  25. 25. Management of foot ulcers <ul><li>Site and depth </li></ul><ul><ul><li> Neuropathic – plantar surface, </li></ul></ul><ul><ul><li>over bony deformity </li></ul></ul><ul><ul><li> Ischaemic/neuro-ischaemic –tips of toes, lateral border of foot </li></ul></ul>
  26. 26. Management of foot ulcers <ul><li>Signs of infection </li></ul><ul><ul><li> Fever, pain,  WBC/ESR often absent </li></ul></ul><ul><ul><li> Probe to bone test for osteomyelitis: if you </li></ul></ul><ul><ul><li>can see exposed bone of you can feel it </li></ul></ul><ul><ul><li>easily with a sterile probe, it is very likely </li></ul></ul><ul><ul><li>that he has osteomyelitis </li></ul></ul><ul><ul><li> Deep tissue specimens if deep infections suspected </li></ul></ul>
  27. 27. Ulcer treatment <ul><li>Relief of pressure </li></ul><ul><li>Restoration of skin perfusion </li></ul><ul><li>Treatment of infection </li></ul><ul><li>Metabolic control </li></ul><ul><li>Local wound care </li></ul><ul><li>Instruction of patients and relatives </li></ul><ul><li>Determine the cause and prevent recurrence </li></ul>
  28. 28. Diagnosis of infection <ul><li>Presence of purulent discharge from an ulcer </li></ul><ul><li> 2 – redness, induration, pain, tenderness, warmth </li></ul><ul><li>Most do not have fever or leukocytosis </li></ul><ul><li>Thoroughly inspect all wounds </li></ul><ul><li>Probe to bone test </li></ul><ul><li>Xray </li></ul>
  29. 29. Microbiology <ul><li>Superficial swabs ARE NOT meaningful </li></ul><ul><li>Deep tissue specimens following debridement </li></ul><ul><li>Culture of bone specimens </li></ul>
  30. 30. Classification of Diabetic Foot Ulcer <ul><li>• Grade 0 — No ulcer in a high risk foot. </li></ul><ul><li>• Grade 1 — Superficial ulcer involving the full skin thickness but not underlying tissues </li></ul><ul><li>• Grade 2 — Deep ulcer, penetrating down to ligaments and muscle, but no bone involvement or abscess formation </li></ul><ul><li>• Grade 3 — Deep ulcer with cellulitis or abscess formation, often with osteomyelitis </li></ul><ul><li>• Grade 4 — Localized gangrene. </li></ul><ul><li>• Grade 5 — Extensive gangrene involving the whole foot. </li></ul>
  31. 31. Grade 1 and 2 diabetic foot ulcer Early digital ulceration following minor injury Neuropathic and arteriopathic ulcer following ill-fitting new shoe Superficial ulcer confined to full-skin thickness
  32. 32. Management of grade 1 and 2 lesions <ul><li>Extensive debridement, </li></ul><ul><li>Good local wound care, and </li></ul><ul><li>Relief of pressure on the ulcer </li></ul><ul><li>Close monitoring is required </li></ul><ul><li>Hospitalization for bed rest and iv antibiotic therapy is advisable if the ulcer does not improve. </li></ul>
  33. 33. Management of grade 1 and 2 lesions <ul><li>Cultures of the ulcer by curettage </li></ul><ul><li>Aerobic gram-positive cocci present in 89%, sole pathogen 42% </li></ul><ul><li>Aerobic gram-negative bacilli 36% </li></ul><ul><li>Anaerobes 17%, usually as a second organism. </li></ul>
  34. 34. Management of grade 1 and 2 lesions <ul><li>Oral cephalexin 500 mg qid or clindamycin 300 mg tds for 2 weeks </li></ul><ul><li>Ulcers healed in 75% in 2 weeks </li></ul><ul><ul><li>further 15% cured with additional treatment </li></ul></ul><ul><li>Success of therapy did not correlate with in vitro antimicrobial susceptibility </li></ul>
  35. 35. Heel ulcer - Infected blister
  36. 36. Management of grade 3 lesions <ul><li>Evaluation for peripheral arterial disease </li></ul><ul><li>Evaluation for bone involvement </li></ul><ul><ul><li> Osteomyelitis is likely (PPV ~ 90%) </li></ul></ul><ul><ul><ul><li>if bone can be seen at the floor of a deep ulcer </li></ul></ul></ul><ul><ul><ul><li>if it can be easily detected by probing the ulcer with a sterile, blunt, stainless steel probe </li></ul></ul></ul><ul><ul><ul><li>ulcer deeper than 3 mm </li></ul></ul></ul><ul><ul><ul><li>ESR > 40 mm/hour. </li></ul></ul></ul>
  37. 37. Management of grade 3 lesions <ul><li>Surgical debridement, </li></ul><ul><li>Culture of material obtained </li></ul><ul><li>from deep in the ulcer, and bone biopsy </li></ul><ul><li>A prolonged course (10 to 12 weeks) of intravenous antibiotics is still standard </li></ul><ul><li>IV antibiotic for 48 hours until the culture results are available, followed by appropriate </li></ul><ul><li>oral antibiotic therapy at home eg ciprofloxacin </li></ul>
  38. 38. Management of grade 4 and 5 lesions <ul><li>Urgent hospital admission and surgical consultation </li></ul><ul><li>Amputation is often needed. </li></ul>Infected big toe Minor lesion 2 months previously
  39. 39. Osteomyelitis - Diagnosis <ul><li>Plain xray </li></ul><ul><ul><li> Poor sensitivity </li></ul></ul><ul><ul><li> Poor specificity – osteopaenia, joint disorganisation due to neuropathy </li></ul></ul><ul><li>High ESR - >60-70 mm/hr </li></ul><ul><li>Bone scans </li></ul><ul><ul><li> Good sensitivity </li></ul></ul><ul><ul><li> Poor specificity </li></ul></ul>osteomyelitis
  40. 40. Osteomyelitis - Diagnosis <ul><li>White blood cell scan </li></ul><ul><li>MRI </li></ul><ul><ul><li>Good sensitivity – 90-95% </li></ul></ul><ul><ul><li>Good specificity </li></ul></ul><ul><li>Gold standard – culture from bone specimen, HPE </li></ul>
  41. 41. Antibiotic therapy <ul><li>Non limb threatening infections in previously untreated </li></ul><ul><ul><li> Mild infections </li></ul></ul><ul><ul><ul><li>2 weeks cloxacillin, clindamycin, cephalexin </li></ul></ul></ul><ul><ul><li> Superficial ulcers with cellulitis </li></ul></ul><ul><ul><ul><li>IV cloxacillin, cefazolin </li></ul></ul></ul>
  42. 42. Antibiotic therapy <ul><li>Limb-threatening infections </li></ul><ul><ul><li> Ampicillin-sulbactam </li></ul></ul><ul><ul><li> Ticarcillin-clavulanate </li></ul></ul><ul><ul><li> Piperacillin-tazobactam </li></ul></ul><ul><ul><li> Clindamycin + 3G cephalosporin </li></ul></ul><ul><ul><li> Clindamycin + ciprofloxacin </li></ul></ul>
  43. 43. Conclusion <ul><li> Diabetic foot infections are common </li></ul><ul><li> Associated with a high degree of morbidity and significant mortality </li></ul><ul><li> Management requires a multidisciplinary approach </li></ul><ul><li> Healing of ulcers can be achieved in 80-90% of cases </li></ul>
  44. 44. <ul><li>Approach to Charcot foot </li></ul>
  45. 45. Charcot Neuroarthropathy Background <ul><li>originally described in 1868 by Jean Martin Charcot </li></ul><ul><li>massive joint destruction, subluxation and dislocation was seen </li></ul>Charcot Neuroarthropathy
  46. 46. Charcot - Background <ul><li>Predisposing conditions: </li></ul><ul><ul><ul><li>diabetes mellitus </li></ul></ul></ul><ul><ul><ul><li>alcoholism </li></ul></ul></ul><ul><ul><ul><li>syringomyelia </li></ul></ul></ul><ul><ul><ul><li>spinal cord lesions </li></ul></ul></ul><ul><ul><ul><li>and others </li></ul></ul></ul><ul><li>Today, most common in diabetics, commonly in the lower extremity </li></ul>Charcot Neuroarthropathy
  47. 47. Charcot Foot <ul><li>Radiographic hallmarks: </li></ul><ul><ul><li>Bony destruction, fragmentation </li></ul></ul><ul><ul><li>Bony remodeling </li></ul></ul><ul><ul><li>Joint destruction, subluxation and dislocation </li></ul></ul>Charcot Neuroarthropathy
  48. 48. Clinical Presentation <ul><li>Red, hot, swollen foot </li></ul><ul><li>Typically painless or only mildly painful unilateral swelling of extremity </li></ul><ul><li>Can mimic cellulitis, gout, osteomyelitis and even DVT </li></ul><ul><li>Plain films may appear normal initially </li></ul>Charcot Neuroarthropathy
  49. 49. Clinical Presentation <ul><li>Ortho exam may reveal joint hypermobility with crepitus +/- cutaneous ulceration </li></ul><ul><li>As disease progresses, longitudinal and transverse arches of foot may collapse, creating a rocker bottom foot </li></ul>Charcot Neuroarthropathy
  50. 50. Clinical Presentation <ul><li>Some degree of sensory deficit always present </li></ul><ul><li>Deep tendon reflexes, vibratory sensation, and proprioception may be diminished or absent </li></ul><ul><li>Due to autonomic sympathectomy, may see bounding pulses, calor, rubor, tumor and anhidrosis +/- xerosis </li></ul>Charcot Neuroarthropathy
  51. 51. Clinical Presentation <ul><li>Acute presentation </li></ul>Charcot Neuroarthropathy
  52. 52. Clinical Presentation <ul><li>Rocker bottom foot </li></ul>Charcot Neuroarthropathy
  53. 53. Clinical Presentation <ul><li>Rocker bottom foot </li></ul>Charcot Neuroarthropathy
  54. 54. THANKS

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