This case report describes a 55-year-old woman with diabetes who presented with a foot ulcer. She developed swelling and blackening of her left second toe after being bitten by a cat. The ulcer progressed in size over time. She had a history of diabetes for 5 years and was on antidiabetic treatment. Examination found a large irregular ulcer on the top of her foot. Investigations showed elevated blood sugars. She underwent ray's amputation of the second toe and was treated with antibiotics, insulin, and other medications. The differential diagnoses considered were wet gangrene, varicose ulcer, and venous ulcer.

1. DIABETIC FOOT
MADE BY : VISHRANT AMIN
GMERS MEDICAL COLLEGE ,VALSAD

2. DEFINITION
 According to WHO Diabetic Foot defined
as pathologic consequences, including
infection , ulceration and/or destruction of
deep tissues associated with neurologic
abnormalities, various degrees of
peripheral vascular disease, and/or
metabolic complications of diabetes in the
lower limb”.

3. INTRODUCTION TO DM
 Diabetes mellitus is a group of metabolic diseases characterized by
hyperglycemia resulting from defects in insulin secretion, insulin action, or
both.
 The chronic hyperglycemia of diabetes is associated with long-term
damage, dysfunction, and failure of various organs, especially the eyes,
kidneys, nerves, heart, and blood vessels.
 Diabetic foot is defined as any foot pathology that results directly from
diabetes or its long term complications

4. WHO CLINICAL CLASSIFICATION OF
DIABETES MELLITUS
1.Diabetes mellitus(DM)
 Type 1 or Insulin-dependent diabetes mellitus
 Type 2 or Non-insulin dependent diabetes mellitus
 Malnutrition related diabetes mellitus(MRDM)
 Other types
(secondary to pancreatic, hormonal , drug-induced, genetic and other)
2.Impaired glucose tolerance(IGT)
3.Gestational diabetes mellitus(GDM)
4

5. TYPES OF DIABETES
Type 1 diabetes Type 2 diabetes Gestational diabetes
• Lack of insulin
• Autoimmune
• Usually children
• Insulin resistance
• Lifestyle factors
• Usually adults
• Insulin resistance
• During pregnancy
• Risks to mother and
child

6. FACTORS FOR DEVELOPING DM
AGENT FACTORS
Insulin deficiency caused by:
 Pancreatic disorders
 Defective insulin production
 Destruction of beta cells
 Decreased insulin sensitivity
 Genetic defects
 Autoimmunity
HOST FACTORS
Age
Sex
Genetic factors
Genetic markers
Immune mechanisms
Obesity
Maternal diabetes

7. MAGNITUDE OF DM
 Globally 422 million people have diabetes
 90% Type II
 The greatest number of people with diabetes are between 40 and
59 years of age
 Global prevalence-9.1%
 Asians shows more vulnerability
 The prevalence of Diabetes in India is 8.6%.
 India is set to become the diabetes capital of the world with a
projected 109 million individuals with diabetes by 2035.
 Currently 63 million suffered from DM.
 80% of diabetic death from lower and middle class .
 Every six seconds a person dies from diabetes
 1.5million die each year due to diabetes related causes.
 India ranks second (after China) with more than 66.8
million diabetics in the age group of 20-70.

8. BURDEN OF DF
 Diabetic Foot (DF) is one of the most common complications for admissions imposing
tremendous medical and financial burden on our healthcare system.
 The life time risk of a person with diabetes having a foot ulcer could be as high as 25% and is the
Commonest reason for hospitalization of diabetic patients (about 30%) .and they absorbs about
20% of the total health-care costs, more than all other diabetic complications.
 The prevalence of foot ulcer in diabetics attending a center managing diabetic foot (both indoor
and outdoor setup) in India is 3%.
 Foot ulcers among outpatient and inpatient diabetics attending hospitals in rural India was found
to be 10.4%.
 Peripheral vascular disease (PVD) occurs in about 3.2% diabetics below 50 years of age
and rises to 55% in those above 80 years of age.
 15% of those with diabetes for a decade suffer from diabetic foot, where as it increases to almost
50% by another decade.

9. MORBIDITY AND MORTALITY OF DF
• Approximately, 85% of non-traumatic lower limb amputations are seen in patients
with prior history of diabetic foot ulcer.
• Each year, more than 1 million people with diabetes lose at least a part of their leg
due to diabetic foot. It shows that every 20 seconds a limb or its part is lost in the world
somewhere.
• 45,000 legs are amputated every year in India.
• The vast majority (75%) of these are probably preventable because the amputation often
results from an infected neuropathic foot.
• More than half of all foot ulcers become infected, requiring hospitalization, while 20% of infections
result in amputation.
• After a major amputation, 50% of people will have the other limb amputated within two years time.
• People with a history of diabetic foot ulcer have a 40% greater 10-year death rate
than people with diabetes alone.

10. Bibilography:
 WORLD HEALTH ORGANIZATION
 DIABETIC FOOT SOCIETY OF INDIA
 INTERNATIONAL DIABETES FEDERATION
 AMERICAN DIABETES ASSOCIATION

11. RISK FACTORS
 DIABETES MELLITUS
 Sedentary lifestyle
 Diet
 Dietary fiber
 Malnutrition
 Alcohol
 Viral infections
 Chemical agents
 Stress
 Socioeconomic status
 Urbanization
 DIABETIC FOOT
 Male sex
 DM > 10 years duration
 Peripheral neuropathy
 Abnormal foot structure
 Peripheral arterial disease
 Evidence of ischemia in foot ( ABI < 0.9)
 Callus
 Inappropriate footwear
 Smoking
 H/O previous ulceration / amputation
 Poor glycemic control (HbA1c > 7%)

12. CLINICAL FEATURE
 DIABETES MELLITUS
 Image
 DIABETIC FOOT
 Pain in the foot
 Ulceration
 Hair loss
 Dry skin
 Absence of sensation
 Absence of pulsations:-Posterior tibial
and dorsalis pedis arteries
 Chronic Osteomyelitis
 Abscess formation
 Gangrene

13. PATHOPHYSIOLOGY
 Factors leading to development of diabetic foot:
 Diabetic polyneuropathy – loss of sensation
 Diabetic macroangiopathy – peripheral arterial occlusive disease
 Diabetic microangiopathy – thickening of basement membranes
 Diabetic osteoathropathy – abnormal foot biomechanics
 Vascular disease
 Reduced resistance to infection
 Delayed wound healing
 Reduced rate of collateral vessel formation

15. PERIPHERAL NEUROPATHY
• IT COMMONLY MENIFESTS AFTER ABOUT 10 YEARS OF LIFE
• NEUROPATHY CAN BE DISTAL AND DIFFUSE WITH A STROCKING TYPE OF DISTRIBUTION.
 3 TYPE OF NEUROPATHY
I. Sensory neuropathy
II. Motor neuropathy
III. Vegetatative neuropathy
 SENSORY NEUROPATHY
Predominates
Large fibres - tactile and deep sensitivity
Small fibres - pain and heat sensitivity
Nerve damage is due to formation of sorbitol from the sugar.
SORBITOL causes demyelination of nerve fibres.

16.  MOTOR NEUROPATHY
 Weakness and atrophy of the intrinsic
muscles of the foot-clawtoe
 Loss of joint mobility
 Secondarily, it contributes to loss of
joint mobility, which is also due to
conjunctive tissue glycosylation inducing
fibrosis of the joint, soft tissue and skin
 VEGETATIVE NEUROPATHY
 Induces skin dryness with crevasses and
fissures providing entry points for
infection
 Hyperkeratosis in reaction to
hyperpressure
 Opens arteriovenous shunts and
induces deregulation of capillary flow
 The neuropathic foot is hot, with
frequent edema and dilated dorsal
veins

17. ANGIOPATHY
 Macroangiopathy
 Atheromatous lesions -
classically showing multi-
segment and distal
involvement
 Femoral, Popliteal, Tibial,
Peroneal and Pedis Arteries

18.  Microangiopathy
 Thickening of the capillary
membrane, induce
abnormal exchange and
aggravate tissue ischemia
 Induces chronic ischemia,
which is an aggravating
factor in foot lesions
 The foot is cold and the skin
becomes thin and shiny

19. The Lewis Triple Flare Response is absent
in diabetic patients affecting wound
healing
LEWIS TRIPLE FLARE RESPONSE

20. Autonomic Neuropathy
 Regulates sweating and perfusion to
the limb
 Loss of autonomic control inhibits
thermoregulatory function and
sweating
 Result is dry, scaly and stiff skin that is
prone to cracking and allows a portal
of entry for bacteria

21. STAGES OF ULCER DEVELOPMENT

22. STAGES OF ULCER DEVELOPMENT

23. FACTOR RESPONSIBLE FOR DF DEVELOPMENT
 CHEMICAL,THERMAL,MECHANICAL WOUND

24. RISK GROUP FOR DEVELOPMENT OF DF

25. ULCER CLASSIFICATION
 Wagner Meggitt Classification
 Texas Classification
 Pedis Classification
 King’s Classification

26. Wagner Meggitt Classification

27. Texas Classification

28. PEDIS Classification
Based on five parameters
 Perfusion
 Extent
 Depth
 Infection
 Sensitivity

29. 
 PAD: Peripheral arterial diseases,
 CLI : Critical limb Ischemia
 SIRS : Systemic Inflammatory Response Syndrome

30. King’s Classification

31. TYPICAL FEATURES OF DIABETIC
FOOT ULCER ACCORDING TO
ETIOLOGY
Feature Neuropathic Ischemic Neuroischemic
Sensation Sensory loss
Painless
Painful Degree of sensory loss and
painless
Callus/necrosis Callus present and often thick Necrosis common Minimal callus
Prone to necrosis
Wound bed Pink and granulating,
surrounded by callus
Pale and sloughy with poor
granulation
Poor granulation
Foot temperature and pulses Warm with pulses present Cool with absent pulses Cool with absent pulses
Other Dry skin and fissuring Delayed healing High risk of infection
Typical location Weight bearing areas of the
foot such as metatarsal heads,
the heel and over the dorsum of
clawed toes
Tips of toes, nail edges and
between the toes and lateral
borders of the foot
Margins of the foot and toes

32. A 55 yrs old married hindu female patient named Jayaben Lakshman Pawar residing at
Umargao,Maharashtra belongs to lower socioeconomical status was admitted on 16/8/2016 at Civil
Hospital, Valsad with chief complain of Swelling over the foot and small blackish area over left
second toe due to cat bites on her left second toe. And she developed Fever after a 4 days of
admission.
CASE

33. ODP:
 Patient was relatively well before 2 aug 2016. On 2 aug 2016 cat bites on her second
toe.
 On same day she visited near by government hospital with pain and swelling over the
left foot .
 She was treated for primary care and refered to Civil hospital-valsad for further
treatment.
 After that she develop sever pain & blackening area over the left second toe. So she
visited valsad civil hospital on 16/8/2016 and she was admitted .
 At the time of admission there was blackening of second toe present after that ulcer
developed from second toe and surroundings area which gradually increase in size
spread to following area:
 whole dorsal surface of foot
 anterior : 6 inch above from ankle
 Posterior : 7.5 inch above from ankle
 Medially : 3.5 inch above from ankle
 Laterally : 8 inch above from ankle
 After 4 days of admission she developed a mild Fever which was subsides after a week
.And again she developed a fever 3 days ago.

34.  NEGATIVE HISTORY
• No other ulcer on the body
• No Trauma Previously
• No Discharge
• No Bleeding
 PAST HISTORY
• Known case of DM since 5 yrs
• TB 10 yrs ago ( treated)
• No jaundice
• No Hypertension
• No Blood Transfusion
• No major surgeries
 FAMILY HISTORY
• Nothing significant

35.  PERSONAL HISTORY
 Diet: mix
 Appetite : increased
 Sleep : adequate
 Bowel habit : Once in 3 days
 Bladder : 10-12 times a day
 Addiction : NO
 Allergy : No
 Drug : Antidiabetic treatment

36. GENERAL EXAMINATION
 Patient was conscious ,cooperative and well oriented to time, place ,person .
 Built: Well
 Nourishment : Well
 Pallor : Mild
 Icterus : absent
 Cyanosis : absent
 Clubbing : absent
 Odema : absent
 Inguinal lymphadenopathy
 No dilated veins or scars

37.  VITALS
 Temperature : Normal by palpatory method
 Pulse : 86 bpm with normal rate ,rhythm , force, tension ,volume and condition of arterial
wall in rt radial artery in supine position.
 Respiratory rate : 18 Breath /min by inspection
 BP : 126-84 mm hg in supine position in right brachial artery by auscultatory method.

38. LOCAL EXAMINATION
 INSPECTION
 SIze :
 Approximately
whole dorsal surface of foot
 anterior : 6 inch above from ankle
 Posterior : 7.5 inch above from ankle
 Medially : 3.5 inch above from ankle
 Laterally : 8 inch above from ankle
 Shape : Large irregular
 Number : single
 Position: over the dorsal surface and leg
 Edge : slopped edges , slight red tissue
 Margin : irregular
 Floor : Dry, slough , necrotic tissue with visible muscle mass. No granulation tissue seen.
 Base : ulcer reside on muscle mass
 Discharge : No
 Surrounding area : Flaky & thin skin , loss of hair

40. PALPATION
 All inspectory findings are confirmed.
 Tenderness on touching
 Edge : Slopping , Dry and solid
 Margin : Irregular , Dry and solid
 Base: Slight induration on pressing
 Depth : 7 to 8 mm
 No bleeding on touch
 Relation with deeper structure : fixed to underlying structure.
 Temperature : cold on ulcer and toe
 Surrounding Skin : increased temperature

41. INVESTIGATION
 RBS,FBS,PP2BS
 URINE ANALYSIS
 Blood urea
 S.creatinine
 S.bilirubin
 S.G.O.T & S.G.P.T
 CBC
 HB
 CULTURE ,STAINING
 LFT

42. TREATMENT HISTORY
 DRESSING EVERYDAY
 Ray’s Amputation OF LEFT 2ND TOE
 ANTIBIOTIC
• Ceftriaxone
• Culture sensitivity test after that specific antibiotic
 ANTIDIABETIC
• Insulin
 OTHER DRUG
• Inj. Diclo
• Inj. Rantec
• Inj. Emset

43. DIFFERNTIAL DIAGNOSIS
 WET GANGRENE
 VARICOSE ULCER
 VENOUS ULCER
 TRAUMATIC ULCER
 MALIGNANT ULCER

44. Assessment of a Diabetic Foot Ulcer
 Examination of the ulcer
 Blood sugar examination
 Testing for loss of sensation.
 10g Semmes-Weinstein monofilament and standard 128Hz tuning fork are simple
and effective screening tool
 Testing for vascular status. This can be done by palpation of the peripheral pulses,
Duplex ultrasound, Angiography
 Identifying infection and taking culture
 Full blood count, electrolytes, inflammatory markers,HbA1C (ESR, CRP)
 Inspecting feet for deformities
 Assessing bone involvement (Using XRAY or MRI or CT-SCAN)

46.  128 Hz tuning fork - The tuning
fork explores vibratory
sensitivity on the dorsal side of
the 1st metatarsal

47. Assessment Infected Ulcers
 Assessing foot ulcers for the presence of infection is
vital. All open wounds are likely to get colonised with
microorganisms, such as Staphylococcus aureus , and
not necessarily infected. Therefore, the presence of
infection needs to be defined clinically rather than
microbiologically.
An infected ulcer
 Signs suggesting infection
 purulent secretions
 presence of friable tissue
 undermined edges
 foul odour

48. ASSESSMENT STRUCTURAL
ABNORMALITIES AND DEFORMITIES
 Structural abnormalities and deformities lead to bony
prominences which are associated with high mechanical
pressure on the overlying skin.
 This results in ulceration, particularly in the absence of a
protective pain sensation and when shoes are unsuitable.
 Ideally, the deformity should be recognised early and
accommodated in properly fitting shoes before ulceration
occurs.
 Common abnormalities / deformities include:
i. Callus
ii. Bunion
iii. Hammer toes
iv. Claw toes
v. Charcot foot
vi. Nail deformities
Callus on plantar surface
Bunion on the medial border of the foot

49. Claw toes Charcot footNail deformity
ASSESSMENT - SOME COMMON FOOT
DEFORMITIES

50. VASCULAR ASSESMENT
 Peripheral pulses
 Duplex ultrasound
 Angiography
 Ankle-arm index
 Echodoppler
 Angio-MRI
 TcpO2

51.  PULSATION

52. OSTEO-ARTICULAR ASSESMENT
 Standard X-ray
 Signs of Osteitis.
 Neuro - arthropathic lesions
 Comparative assessment
 CT
 confirms osteolysis in case of ambiguous X-ray
 MRI
 It differentiates osteoarthritic from neurogenic osteo-arthropathic lesions
 Reserve it for ‘‘acute foot’’ with cellulitis
 Sometimes USG for aspiration

53. MANAGEMENT
DIABETIC FOOT NEEDS MULTIDICPLINARY
APPORCH
 DEVELOPED COUNTRIES
 TEAM CONSISTS OF
1. PHYSICIAN
2. SURGEON
3. PODIATRIST
4. SPECIALIST NURSE
5. ORTHOTIST
6. RADIOLOGIST
 DEVELOPING COUNTRIES
 THE PRIMARY CARE DOCTOR IS THE ONLY
HELP AVAILABLE
 ORTHOTIST, PODIATRIST, SPECIALIST NURSE
ALL EXTREMELY SCARCE
 THEREFORE, BASIC ASPECTS OF ALL THESE
FIELDS NEED TO BE KNOWN BY EVERY
PHYSICIAN

54. ASPECTS OF PATIENT TREATMENT
 CONTROL OF WOUND OR ULCER SPREAD
 CONTROL OF DIABETES
 CONTROL OF INFECTION
 USE OF MECHANICAL INSTRUMENTS
 AMPUTATION
 REVASCULARIZATION
 EDUCATIONAL CONTROL

55. CONTROL OF WOUND OR ULCER
SPREAD
 WOUND CLEANSING & DRESSING
 A sterile, non-adherent dressing should
cover all open diabetic foot lesions to
protect them from trauma, absorb exudate,
reduce infection and promote healing.
 Dressings should be lifted every day to
ensure that problems or complications are
detected quickly, especially in patients who
lack nociception.
 ADDITIONAL APPROCH
 Skin graft:
 Vacuum-Assisted closure (VAC) pump:

56. DEBRIDMENT OF ULCER
Forcep and a scalpel is the usual technique
by cutting away of all slough and non-viable
tissue.
 Debridement is the removal of necrotic and dead
tissue in order to enhance healing.
 Remove callus in neuropathic foot to lower plantar
pressure
 Assess the true dimension of the ulcer
 Drain exudate and remove dead tissue to render
infection less likely
 Take a deep swab for culture
 Encourage healing and restore a chronic wound to an
acute wound

57. CONTOL OF DIABETES

58. CONTROL OF INFECTION
 Choose an antibiotic regimen
 Severe infection:
 start broad spectrum IV abx (ensure Gram Positive Coverage, gram
negative and anaerobic coverage)
 Mild-Moderate infection:
 Relatively narrow spectrum only covering aerobic Gram Positive
Coverage
 No evidence for anti-anaerobic therapy
 Oral therapy with highly bioavailable agents is appropriate
 Mildly infected open wounds with minimal cellulitis:
 Limited data support the use of topical antimicrobial therapy (B-I)

59. USE OF MECHANICAL INSTRUMENT
Plantar orthoses –
• Insoles have a preventive and sometimes curative
function.
• Basically, they distribute pressure, more rarely with
corrective elements
Orthoplasties –
• Orthoplasties are little molded silicone devices that
protect areas of conflict with the shoe (notably at the
toes)
Shoes –
• Shoes are essential to prevention.
• They may be adapted mass-produced models, semi-
therapeutic or made to measure orthopedic shoes

60.  Various casts are available and all aim to relieve
plantar pressure. Their use is governed by local
experience and expertise
Air cast (walking brace)
A bivalved cast with the halves joined together with Velcro strapping. The
cast is lined with 4 air cells which can be inflated with a hand pump to
ensure a close fit. The cast can be removed easily by patients to check
ulcers and before going to bed.
Scotch cast boot
A simple, removable boot madeup of stockinette, softban bandage, belt
fibreglass tape.
Total contact cast
It is a close-fitting plaster of paris and fibreglass cast applied over
padding. It is very efficient method of redistributing plantar pressure, and
should be reserved for plantar ulcers that have not responded to other
A scotch cast boot
An air cast

63. AMPUTATION
Indications for amputation are:
1. If revascularization is technically impossible
2. If there is substantial tissue necrosis and
functionally useless foot or spreading
infection is present
3. A non healing ulcer that is accompanied by a
higher burden of disease than would result
from amputation.
4. Ischemic rest pain that cannot be managed by
analgesics or revascularization
5. As part of debridement (minor amputation)
6. Spreading cellulitis

64. PROSTHESIS OF AMPUTEE
 INTELLIGENT FOOT JAIPUR FOOT

65. EDUCATIONAL CONTROL
DIABETIC FOOT CARE
DO
 WASH FEET DAILY WITH MILD SOAP & WATER
 CHECK FEET DAILY
 TAKE URGENT TREATMENT OF ANY
PROBLEMS
 WEAR SENSIBLE SHOES
 CHECK SHOES INSIDE AND OUTSIDE BEFORE
WEARING
 MEASURE FEET WHEN BUYING SHOES
 BUY LACE-UP SHOES WITH PLENTY OF ROOM
FOR TOES
 KEEP FEET AWAY FROM HEAT
 SIT INSTEAD OF STANDING
 CHANGE SOCKS FREQUENTLY
DONTS
 USE CORN CURES
 USE HOT-WATER BOTTLES
 WALK BAREFOOT
 CUT CORNS OR CALLUSES BY YOURSELF
 DELAY IN TREATMENT FOR ANY PROBLEM

67. PROGRAM CONDUCTED BY
GOVERNMENT OF INDIA
 NPCDCS (National Program For Prevention And Control Of Cancer,
diabetes, cardiovascular diseases, and stroke )

71. THANK YOU !!!