This document discusses diabetic foot ulcers. The main points are: - Diabetic foot ulcers affect 15-25% of diabetes patients and precede 85% of lower limb amputations. They are costly and preventable. - Neuropathy, vasculopathy, and susceptibility to infections contribute to ulcer development. Neuropathy causes insensitivity, deformity, and trauma while vasculopathy limits blood supply. - Management involves assessing vascular supply, treating infections early, and redistributing plantar pressure through casts, walkers, or therapeutic shoes. Good glucose control also supports immune response and healing.

1. DIABETIC FOOTDIABETIC FOOT
ULCERULCER

2. IntroductionIntroduction
 In 15- 25% of DM patients over lifetimeIn 15- 25% of DM patients over lifetime
 PAD ,neuropathy , deformity ,previousPAD ,neuropathy , deformity ,previous
amputation and infection are contributingamputation and infection are contributing
factorsfactors
 Recurrence over 5 years 50- 70%Recurrence over 5 years 50- 70%
 DFU precede 85% of lower limb amputationsDFU precede 85% of lower limb amputations
 DFU are the most costly and preventableDFU are the most costly and preventable
complication of DMcomplication of DM
 Risk of ampution is 15-46 times more in DMRisk of ampution is 15-46 times more in DM

3. Pathophysiology ofPathophysiology of
DFUDFU
 NeuropathyNeuropathy
 VasculopathyVasculopathy
 Suscptibility to infectionsSuscptibility to infections

4. neuropathyneuropathy
 Sensory , motor ,autonomicSensory , motor ,autonomic
 Nitric oxide blockingNitric oxide blocking
hyperglycemia =inhibit nitric oxide productionhyperglycemia =inhibit nitric oxide production
=increase reactive oxygen=vasoconstriction=increase reactive oxygen=vasoconstriction
and increase LDL=neuropathyand increase LDL=neuropathy
 Maillard reactionMaillard reaction
a reaction of reducing sugars and aminoa reaction of reducing sugars and amino
groups of biomolecules =AGE= atherosclerosisgroups of biomolecules =AGE= atherosclerosis
and agingand aging

5. Neuropathy effectsNeuropathy effects
 Foot deformity and limited jointFoot deformity and limited joint
mobility=callus =inflammation = tissuemobility=callus =inflammation = tissue
injury and necrosis =ulcerationinjury and necrosis =ulceration
 Low sense= repetitive injury =ulcerationLow sense= repetitive injury =ulceration
 Low hydration = xerosis = fissuring =Low hydration = xerosis = fissuring =
ulcerationulceration
 Low production of neuropeptides = lowLow production of neuropeptides = low
wound healingwound healing

6. Vascular diseaseVascular disease
 Micro and macro vascularMicro and macro vascular
 Ischemia present in 90% of amputationsIschemia present in 90% of amputations
 Inflammation = thickening of capillaryInflammation = thickening of capillary
basement membrane and hyalinization =basement membrane and hyalinization =
compromise normal movements andcompromise normal movements and
inelasticity = functional ischemiainelasticity = functional ischemia

7. Inflammatory cytokinesInflammatory cytokines
and suscptibility toand suscptibility to
infectioninfection
 Ulcer = loss of barrier = susceptibility toUlcer = loss of barrier = susceptibility to
infection =biofilm =resistance toinfection =biofilm =resistance to
antimicrobials and immunologic factorsantimicrobials and immunologic factors
=chronic infection and delayed healing=chronic infection and delayed healing
 DM affect normal WBC funtion andDM affect normal WBC funtion and
immune response = decrease hostimmune response = decrease host
resistanceresistance

8. Increased plantarIncreased plantar
pressurepressure
 Callus formationCallus formation
 Motot neuropathy= unequal muscle pull first inMotot neuropathy= unequal muscle pull first in
plantar muscles = cocked up toe ,claw toesplantar muscles = cocked up toe ,claw toes
,hammer toe,hammer toe
 Friction and shear =blister formationFriction and shear =blister formation
 BunionsBunions
 Hyperglycemia =glycosylation of collagenHyperglycemia =glycosylation of collagen
=stiffness odf connective tissue = restricted=stiffness odf connective tissue = restricted
range of motionrange of motion

9. ClinicalClinical
presentationspresentations

10. neuropathyneuropathy
 Increased plantar pressureIncreased plantar pressure
 Sensory ,motor ,autonomSensory ,motor ,autonom
 Diabetic sensorimotor polyneuropathy : 40-50% in 10Diabetic sensorimotor polyneuropathy : 40-50% in 10
yearsyears
 3 mechanisms of injury : footwear ,weight-bearing ,3 mechanisms of injury : footwear ,weight-bearing ,
traumatrauma
 Sensory = monofilament test (absence of 3-4 sites ofSensory = monofilament test (absence of 3-4 sites of
10 )10 )
 Autonomic : anhydrosis = dry skin = fissuringAutonomic : anhydrosis = dry skin = fissuring
 Motor : loss of ankle reflexes ,deformity , wasting ofMotor : loss of ankle reflexes ,deformity , wasting of
muscles ,muscle imbalancemuscles ,muscle imbalance

11. Peripheral vascularPeripheral vascular
diseasedisease
 DFU : neuropathic , ischemic ,neuroischemic .DFU : neuropathic , ischemic ,neuroischemic .
The last two =worse prognosisThe last two =worse prognosis
 Hx and physical examHx and physical exam
 Palpable pulse in foot = 80mmHgPalpable pulse in foot = 80mmHg
palpable pulse in diabetics does notpalpable pulse in diabetics does not
exclude poor perfusionexclude poor perfusion
*Doppler exam of large toe ( toe-brachial*Doppler exam of large toe ( toe-brachial
pressure index ) = gold standardpressure index ) = gold standard
*transcutaneous oxygen tension*transcutaneous oxygen tension

12. Chrcot footChrcot foot
 A late complication of peripheral motor neuropathyA late complication of peripheral motor neuropathy
 Results from repetitive trauma to insensitive bones andResults from repetitive trauma to insensitive bones and
joints of footjoints of foot
 DM is the most common causeDM is the most common cause
 Redness ,swelling ,deformity and increase footRedness ,swelling ,deformity and increase foot
temperaturetemperature
 Most affected : midfoot jointsMost affected : midfoot joints
 DDx : cellulitis ,osteomyelitisDDx : cellulitis ,osteomyelitis
 Non-weight-bearing and immobilization is the keyNon-weight-bearing and immobilization is the key
treatment choicetreatment choice

13. Classification of DFUClassification of DFU
 Meggit-wagner classification :depth andMeggit-wagner classification :depth and
infection = 0-6infection = 0-6
 University of texas : depth and infectionUniversity of texas : depth and infection
and ischemia = 0-4and ischemia = 0-4

14. managementmanagement

15. managementmanagement
 Assesment and optimization of vascularAssesment and optimization of vascular
supplysupply
 Early detection and treatment of infectionEarly detection and treatment of infection
 Appropriate plantar pressureAppropriate plantar pressure
redistributionredistribution
 Good glucose control = immne responseGood glucose control = immne response
BS >310 decrease neutrophil functionBS >310 decrease neutrophil function

16. assessmentassessment
 BPBP
 CBC,Cr ,Hb A1CCBC,Cr ,Hb A1C
 ESR ,CRPESR ,CRP
 Vascular assessment : toe-brachial indexVascular assessment : toe-brachial index
 Toe pressure > 55 mmHg adequateToe pressure > 55 mmHg adequate
 Toe pressure <30 mmHg severe arterial supplyToe pressure <30 mmHg severe arterial supply
 A baseline foot radiographyA baseline foot radiography
 MRI most accurate for osteomyelitisMRI most accurate for osteomyelitis

17. Wound assessmentWound assessment
 LocationLocation
 SizeSize
 DepthDepth
 Wound baseWound base
 ExudateExudate
 Periwound skinPeriwound skin
 Pain levelPain level
 Teperature difference: >3-4 c =infection ,Teperature difference: >3-4 c =infection ,
chrcot jointchrcot joint

18. Infection controlInfection control
 More than half of DFU =skin &soft tissue infectionMore than half of DFU =skin &soft tissue infection
 G+ cocci (staph aureus ) the most commonG+ cocci (staph aureus ) the most common
 Chronic ulcers : multibacterial ( g+ ,g- ,anaerobes)Chronic ulcers : multibacterial ( g+ ,g- ,anaerobes)
 Contamination ,colonization ,infection ,biofilmContamination ,colonization ,infection ,biofilm
 50% of DM with foot infections lack systemic50% of DM with foot infections lack systemic
inflammatory responseinflammatory response
 If ulcer expose bone = osteomyelitis =MRI =boneIf ulcer expose bone = osteomyelitis =MRI =bone
biopsybiopsy
 Bacrerial swab from healthy appearing tissue forBacrerial swab from healthy appearing tissue for
resistant cases to empiric thrapyresistant cases to empiric thrapy

19. Local wound careLocal wound care
 Proper cleansing :normal saline or sterileProper cleansing :normal saline or sterile
waterwater
 Debridment : callus ,wound baseDebridment : callus ,wound base
 Control of localized infectionControl of localized infection
 Moisture balanceMoisture balance

20. Wound debridementWound debridement
 Callus removalCallus removal
 Debridement : surgical , autolytic ,Debridement : surgical , autolytic ,
enzymatic , mechanical ,biologicenzymatic , mechanical ,biologic
 The most selective and fast : surgicalThe most selective and fast : surgical
 Debridement : removal of bacteriaDebridement : removal of bacteria
,unresponsive cells , abnormal,unresponsive cells , abnormal
keratinocyteskeratinocytes

21. Plantar pressurePlantar pressure
redistributionredistribution
 Total contact cast : gold standardTotal contact cast : gold standard
( except heel ulcer ,deep infection( except heel ulcer ,deep infection
,peripheral arterial disease ),peripheral arterial disease )
 Removeble cast walkerRemoveble cast walker
 Therapeutic shoesTherapeutic shoes
 surgerysurgery

22. Wound dressingWound dressing
 Films , hydrogels ,acrylicsFilms , hydrogels ,acrylics
,hydrocolloids ,calcium alginates,hydrocolloids ,calcium alginates
,hydrofibers ,foams,hydrofibers ,foams
 Exudative wound =absorptive dressing ,Exudative wound =absorptive dressing ,
dry wound =moisture balance dressingdry wound =moisture balance dressing

23. Topical antimicrobialsTopical antimicrobials
 Best cleanser : normal saline and waterBest cleanser : normal saline and water
 Topical AB = allergic reaction andTopical AB = allergic reaction and
moisture imbalance = not preferedmoisture imbalance = not prefered
 Topical antiseptic are more properTopical antiseptic are more proper
betadine ,chlorhexidine ,acetic acidbetadine ,chlorhexidine ,acetic acid
,silver compound ,honey ,,silver compound ,honey ,

24. Advanced therapyAdvanced therapy
 Growth factorsGrowth factors
 Negative pressure wound therapyNegative pressure wound therapy
 Hyperbaric oxygen therapyHyperbaric oxygen therapy
 Skin and skin equivalentsSkin and skin equivalents