enjoy the presentation & good luck ..

2. Defnition
• The Diabetic Foot may be defined as a
syndrome in which neuropathy, angiopathy,
and infection will lead to tissue breakdown
resulting in morbidity and possible
amputation ( WHO 1995 )

3. World wide (2013):
2nd Place among world countries !!!!!
Epidemiology and facts

4. Epidemiology and facts
• The overall prevalence of diabetic
foot complications was 3.3%
• whilst the prevalence of foot ulcer, gangrene,
and amputations were 2.05%.
• The prevalence of foot complications increased
with age and diabetes duration predominantly
amongst the male patients.
• Diabetic foot is more commonly seen among
type 2 patients, although it is more prevalent
among type 1 diabetic patients.
PLoS One. 2015 May 6;10(5):e0124446. doi: 10.1371/journal.pone.0124446. eCollection 2015

5. high risk foot ?
Long duration and uncontrolled D.M …Plus one or
more:
• Peripheral neuropathy
• Peripheral vascular disease
• Trauma
• Previous ulcers
• Diabetic nephropathy or retinopathy
• Obesity
• Lack of education
• Male gender ??!!

6. FOOT AT RISK

7. Pathophysiology
• The critical triad of :
1- Neuropathy
2- Foot deformity &
3- Trauma ……………
will lead to ulcer
The presentation in the majority of pts is an
infected ulcer!!

8. Neuropathy
• Sensory : lack of protective sensation
(unrecognized trauma)
• Motor : Change in foot anatomy
(Pressure points) & altered gait
and deformity
• Autonomic : Lack of sweat ( dry &
cracked skin )

9. Stages Of Ulcer Development

10. Assessment
• History
• Physical examinations
• Investigations
• Patient
• Limb or foot
• Wound

11. Assessment………..History
• Generally: fever, chills, sweats, vom…
• Condition : confused, depressed….
• Socially : neglected, lack of home sup.
• Neuropathy : Numbness, loss of sens.
burning, tingling, numbness & nocturnal leg
pains.
• Others : duration, diabetic control, previous
ulceration, smoking, HTN....

12. Assessment………Clinical Ex.
What to look for ?
• V.S : tachycardia, hypotension…
• Signs of volume depletion
• Cognitive state:delirium,stupor, coma
• Limb-Foot:
1- Biomechnics: deformities, change pressure points
2- Vascular status ( arterial, venous, ABI, ischemia, gangrene…
3- Neuropathy ( light touch, vibration, monofilament pressure
4- Examining the feet for structural abnormalities such as nails, calluses,
hammer toes, claw toes and flat foot
5-other : tenia pedis , infection , change in color , hygiene .

13. Diabetic Foot Examination
• D deformity
• I infection
• A atrophic nails
• B breakdown of skin
• E oedema
• T temperature
• I ischemia
• C callosities
• S skin colour

14. Neurologic assessment
 Temperature
 Vibration Sense
 Pressure Sense
 Light Touch
 Proprioception (Romberg’s Sign)
 Superficial Pain
 Reflexes

15. • The monofilament should be placed against
intact skin (without callus) and allowed to
buckle.
• The patient should have his or her eyes closed
during testing and be given a forced choice
i.e. asked “ Do you feel the pressure at time A
or time B?”
Monofilament Test:

17. Testing 10 sites (plantar to toes and metatarsal heads
1, 3 and 5, plantar midfoot medial and lateral and
planter heal , 1st web space
• The person who
cannot feel at
least 7 of 10
pedal sites
tested is
considered to
have an absent
protective
threshold.

18. Ulcer assessment
1. Site, size and shape
2. Edges
3. Establish its depth and involvement of deep structures
4. Examine it for purulent exudates, necrosis, sinus tracts, and
odor
5. Assess the surrounding tissue for signs of edema, cellulitis,
abscess, and fluctuation
6. Perform a vascular evaluation.
7. The ability to gently probe through the ulcer to bone has been
shown to be highly predictive of osteomyelitis.
8. Establish the ulcer's etiology
9. Exclude systemic infection

19. Classification of diabetic foot ulcer
Wagner Grading System
• Grade 0 skin intact but "foot at risk"
• Grade 1: Superficial Diabetic Ulcer & localised
• Grade 2: Deep ulcer & extension
– Involves ligament, tendon, joint capsule or fascia
– No abscess or Osteomyelitis
• Grade 3: Deep ulcer with abscess or Osteomyelitis
• Grade 4: Gangrene to portion of forefoot
• Grade 5: Extensive gangrene of entire foot

20. Classification of diabetic foot ulcer

21. Neuropathic foot ulcer.
Khanolkar M et al. QJM 2008;101:685-695
© The Author 2008. Published by Oxford University Press on behalf of the Association of
Physicians. All rights reserved. For Permissions, please email:
journals.permissions@oxfordjournals.org

22. The Charcot foot.
Khanolkar M et al. QJM 2008;101:685-695
© The Author 2008. Published by Oxford University Press on behalf of the Association of
Physicians. All rights reserved. For Permissions, please email:
journals.permissions@oxfordjournals.org

23. Effects of Diabetic Peripheral
Neuropathy

24. Vascular assessment
• History
• Changes in skin
• Pulses
• Exercise Testing
• ABPI
• Duplex
• Angiography

25. Ischaemic foot ulcer.
Khanolkar M et al. QJM 2008;101:685-695
© The Author 2008. Published by Oxford University Press on behalf of the Association of
Physicians. All rights reserved. For Permissions, please email:
journals.permissions@oxfordjournals.org

26. Assessment…….Infection
Infection is diagnosed clinically by
• The presence of purulent secretion
OR
• At least 2 of the cardinal local manifestations
of inflamation
• Hotness
• Redness
• Swelling
• Function loss or pain

27. Classification of diabetic foot infection
• Minimal inflammation with no pus = 1
• 2 or more signs or ~2cm erythema around the
ulcer or superficial path. and no systemic
manifistations = 2
• As above plus deeper infection, lymphangitis
,abscess or gangrene =3
• As above with systemic or metabolic instability = 4

28. Classification of diabetic foot infection
Non-Limb-threatening
Infections:

29. Classification of diabetic foot infection
Limb-threatening Infection:

30. Summary of ulcer

31. Investigations
• Bloodwork for high BS, DKA, hyperosmolar state…..
• Gram staining and culture
• Imaging
- Plain X-ray
- MRI ?
- Doppler – Angiogram
- US? For deep abscess
- Doppler and ABI

32. Prevention
• Early detection of neuropathy
• Educate patient about
- Optimizing glycemic control
- Using appropriate footwear
- Avoid foot trauma
- Perform daily self examination
- Smoking cessation
• Refer patient with critical ischemia

33. Five cornerstones of management
of the diabetic foot
The situation can be changed & possibly
reduce amputation rates between 50% -85%
by:
1- Regular inspection and examination of the foot and patient
education
2- Identification of the foot at risk.
3- Education of patient, family and healthcare providers.
4- Appropriate footwear.
5- Multidisciplinary approach & treatment of ulcerative and
non-ulcer pathology

34. Patient education
Decreases the chance of occurrence
– Foot hygiene
– Daily inspection
– Proper footwear
– Prompt treatment of new lesions
Must take an active role in their care
– Disease management
– Routine nail care
– Ulcer management
Elective surgery to correct structural
deformities before ulcerations occur

35. A multidisciplinary approach
• Providing :
- Debridement,
- wound care,
- Adequate vascular supply,
- Metabolic control,
- Antimicrobial treatment and
-Relief of pressure (offloading) are essential in the
treatment of foot ulcer.

36. Approach to foot wound in diabetics
• ……Principles of wound care
1- Determine the need for surgery
Ranges from debridement to revascularization
Determine life- or limb-threatening condition ( NF, GG, Ischemia…. )
2- Formulate wound care plan
- Daily inspection
- Dressing and debridement as needed
- Removal of pressure…..
3- Twice- weekly follow up for outpatients
4- WBC, ESR, C-RP, culture … are of limited value

37. Approach to diabetic foot ulcer
According to ulcer stage
0 At-risk foot, no ulceration : Patient education,
accommodative footwear, regular clinical examination
1 Superficial ulceration, not infected :Offloading with total
contact cast (TCC), walking brace, or special footwear
2 Deep ulceration exposing tendons or joints : Surgical
debridement, wound care, offloading, culture-specific
antibiotics
3 Extensive ulceration or abscess : Debridement or partial
amputation, offloading, culture-specific antibiotics

38. Approach to ischemic diabetic foot
Ischemia Classification
A Not ischemic : no treatment
B Ischemia without gangrene: Noninvasive vascular
testing, vascular consultation if symptomatic
C Partial (forefoot) gangrene :Vascular consultation and
debridement
D Complete foot gangrene : Major extremity
amputation, vascular consultation

39. Approach to diabetic foot infection
Antibiotics Empirical antibiotics
• Benzylpenicillin or ampicillin – Streptococcus sp.
• Oxacillin, nafcillin or 1 st generation cephalosporin (eg. cefazolin) –
Staphylococcus sp.
• Quinolone + aminoglycoside (gentamycin) – Pseudomonas sp.
• Methicillin-resistant Staphylococcus aureus – vancomycin or cotri-moxazole
• Clostridial species are sensitive to a combination of penicillin G and clindamycin
Duration of antibiotic treatment
* 1-2 weeks course for mild to moderate infections
* more than 2 weeks for more serious infections
* 6 - 8weeks for osteomyelitis
* If all infected bone is removed,a shorter course (1-2 weeks) of antibiotics, as for
soft tissue infection, may be adequate

40. Offlaoding
Remove pressure from the affected site is
essential
•How ?
- Footwear
- Specialised
offloading
devices

41. Offlaoding
• Footwear
Good shoes are integral to good foot health

42. Key Message

43. Mission:… Happy Feet
QUSTIONS ?