Management of diabetic foot

1. Diabetic Foot
Prof. NAA Mbembati
MD5 lecture

2. Outline
 Introduction
 Diabetic Foot
 Pathophysiology of foot ulceration
 Diabetic Neuropathy
 Peripheral Vascular Disease
 Infection
 Assessment
 Management

3. Introduction
 Diabetes Mellitus =a group of metabolic
disorders characterized by hyperglycaemia
which results from defects in insulin
secretion , insulin action or both.
 Types:
 Type 1-complete or near total insulin
deficiency
 Type 2-
 Insulin Resistance
 Impaired Insulin Secretion

4. Risk factors for Diabetes Mellitus
 Obesity-BMI >25Kg/m2
 Family History of Diabetes
 H/O Gestational Diabetes in females
 Hypertension

5. Diagnosis of Diabetes Mellitus
 Symptoms of Diabetes plus RBG
.11.1mmol/L
 Fasting Blood Glucose >7mmol/L
 Abnormal glucose tolerance test

6. Complications of Diabetes Mellitus
 Acute complications-
 DKA
 Hyperglycaemic hyperosmolar state.
 Chronic complications:
 Vascular
 Neuropathic
 Polyneuropathy
 Mononeuropathy
 Autonomic

7. Diabetic foot
Definition-A foot affected by
ulceration that is associated
with neuropathy and/or
peripheral arterial disease of
the lower limb in a patient
with diabetes.

8. Foot ulcers-causes:
Foot ulcers:Causes:
 Peripheral arterial disease
Atherosclerosis-occurs at young age and
more severe in diabetics
This will lead to vaso-occlusive disease-
ischaemic changes
Microangiopathy –impaired circulation-
poor healing
 Results/effects of vaso-occlusion:
 If no sepsis-dry gangrene
With sepsis-wet gangrene

9. Diabetic Foot
 Foot ulcers:Causes:
 Infection:
 May follow injury to skin trauma, skin
cracks from dry anhidrotic skin
 Other foot infection eg athletes’
foot(Fungal infection between toes)
 Infected pressure sores
 Sepsis with tissue necrosis and pus
formation follows fascial planes

10. Diabetic Foot
 Foot ulcers:Causes:
 Neuropathy-
 Lack of sensation-microtrauma-pt
unaware
 Motor+sensory loss-abnormal foot muscle
biomechanics lead to structural changes(-
hammer toe, Charcots Joint, claw
deformity)
 Autonomic neuropathy-anhidrosis-dry
cracked skin-infections

11. Clinical presentation
 Vaso-occlusion –pain; but in diabetes pain
maybe absent due to neuropathy
 Gangrene maybe dry or wet
 Ulceration
 Infection
 Joint deformity

12. Wagner classification of diabetic ulcers
 -0 - Intact Skin
-1 - Superficial ulcer of skin or subcutaneous
tissue
2 - Ulcers extend into tendon, bone, or
capsule
-3 - Deep ulcer with osteomyelitis, or abscess
4 - Gangrene of toes or forefoot
-5 – Mid-foot or hind-foot gangrene

13. STAGES OF ULCER DEVELOPMENT

14. STAGES OF ULCER DEVELOPMENT

19. Assessment
 Examine the ulcer according to principles of
ulcer examination including
 Lymph node examination
 Pulses
 Sensation
 Depth of ulcer
 Wagner classification
 Neuropathy Symptoms Score

20. Investigations
 Urine ketones, proteins
 Wound swabs-culture/sensitivity
 Blood counts
 X-rays of feet/bones
 Glucose levels in Blood, urine
 MRI can be used to detect
osteomyelitis/deep seated abscesses
 Other investigations as for other affected
systems

21. Management of diabetic foot
 Debridement-to remove all debris and
necrotic tissues. This improves healing by
promoting granulation tissue.
 Off-loading-remove pressure on plantar
ulcers-promotes ulcer healing by providing
total rest to the ulcer. Maybe by-total
contact POP cast or removable cast
walkers; but also half shoes.
 Dressings-which provide moist
environments-most commonly saline

22. Prevention and patient awareness
 Glycaemic control
 Stop smoking, alcohol,
 Regular inspection & examination of foot &
foot wear (remember pt may have visual
problems-cataract)
 Identification of high risk patients
 Education of patient, family & health care
providers
 Appropriate foot wear, including inspection
of shoes
 Treatment of other concomitant diseases