The document discusses the evaluation and treatment of diabetic foot problems. It outlines the importance of assessing a patient's medical history, examining the foot and lower limb for issues like neuropathy, vascular disease and foot deformities, and investigating for conditions like infection. Treatment involves wound care, reducing pressure on ulcers through offloading techniques, managing infection, improving vascular issues, and potentially surgical interventions like debridement or amputation.

1. Diabetic Foot (siti zarina)

2. Why you should wake up and focus on this presentation? 2006 Third National Health Morbidity Survey a) prevalence rate of diabetes mellitus has been reported to have increased from 8.3% in 1996 to 14.9% in 2006 1 b) prevalence of lower limb amputation among patients with diabetes was 4.3%. c) Our MBBS exam

4. HISTORY

5. General and medical history Hx presenting foot complain and duration Duration of diabetes, management, control and complication Social history Allergy and any medication Past medical and surgical history Habits: walks barefoot? Wets feet at work? Wear socks? Walks a lot?

6. History of foot problems Daily activity and current diabetic foot status What footwear? Foot care? Callus formation Deformities and previous surgery? Neuropathy and ischemic symptoms? Skin and nail problems?

7. History of ulcers Site, size, duration, odour, type of drainage Precipitating factor, trauma? Recurrences? Associated infections symptoms Any hospitalizations and what treatment Wound care Patient compliance Previous trauma or surgery Features of Charcot joint

10. Physical examination General : any sign of inflammation Local examination : compare both limbs. Check the normal one first

11. Musculoskeletal status Attitude and posture Orthopaedic deformities Limited joint mobility, muscle strength Tendo-Archilles contractures/equinus/foot drop Gait evaluation Plantar pressure measurement

12. Skin and nails of foot Skin appearance: color, texture, turgor, quality and dry skin Calluses, heel fissures, cracking of skin Nail appearances Presence of hair Ulceration, gangrene, infection Interdigital lesions, tinea pedis

13. Vascular status of foot Pulses Capillary refill time Edema Color change Temperature gradient Venous filling time Changes of ischemia

14. Neurological status of foot Vibration perception Pressure and touch- monofilament 10gm Semmes Weinstein, cotton wool Pain – pin prick Two point discrimination Temperature perception Deep tendon reflexes – ankle and knee Clonus testing, Babinski test and Romberg test

15. Evaluation of foot wear Type and condition of shoes and sandals Fit Shoe wear, pattern of wear, lining wear Foreign bodies Insoles, orthoses

17. Investigation General Glucometer/ Random Blood Sugar, Fasting blood sugar HbA1C FBC U&E ESR UFEME –Ketonuria, CNS Wound and blood culture and sensitivity IMAGING X-rays of foot (AP, Lateral) (to look for soft tissue gas , Charcot jt, fracture, osteomyelitis) CT scan Bone scan and MRI Vascular assessment Doppler , ankle brachial indices (normal value= 1.1. if <0.9, abnormal) Plantar foot pressure

18. Diabetic foot ulcer

20. Neuropathy Peripheral vascular disease Abnormal foot pressure Hyperglycemia Trauma Foot deformity Limited joint mobility Previous ulceration and amputation Poor vision Chronic renal disease Old age Condition of diabetes Neuropathy Peripheral vascular disease Abnormal foot pressure Hyperglycemia Trauma Foot deformity Limited joint mobility Previous ulceration and amputation Poor vision Chronic renal disease Condition of diabetes

21. Pathogenesis Somatic neuropathy - reduced perception to pain Diminished proprioception Clawing of toes Autonomic neuropathy Absent sweating Dry skin fissures Altered blood flow and regulation Distended foot veins; warm foot Charcot neuroarthropathy Peripheral vascular disease Claudication Rest pain Cold extremities Reduced foot pulses Increased foot pressure Callus formation Foot ischemia Foot ulceration Gangrene Infection Amputation Connective tissue changes Limited joint mobility Orthopedic disorder

22. Wagner’s foot ulcer classification

24. Treatment Debridement Wound care Reduction of plantar pressure (Off loading) Treatment of infection Vascular management of ischemia Medical Rx of co-morbidities Surgical management Reduce risk of recurrence

25. Debridement Surgical debridement Involve removal of all non-viable tissue or bone until healthy bleeding soft tissue or bone are encountered. Abscess: immediate I & D. Osteomyelitic bones, joint infection, gangrene digits: require resection or partial amputation. Other type of debridement: mechanical (surgical debridement, high pressure irrigation, wet to dry dressing), Enzymatic Autolytic

26. Wound care Done following debridement. Dressing: normal saline and others (e.g: transparent films, foam, hydrocolloids, calcium alginates, gauze pads, collagen dressings) Ulcer is covered to avoid contamination and trauma. Choice of dressings or topical agents depends on the health care provider’s experience, type and site of ulcer, costs involved and patient’s preferences

27. Off-loading Reduce the pressure to the ulcer. Thus, reducing the trauma to the ulcer and allowing it to heal. Example: Total contact casting Total non-weight bearing Removable walking braces with rocker bottom soles Foot casts or boot Total contact orthoses Healing sandal Patellar tendon bearing braces Half shoe or wedge shoes Healing sandal- surgical shoe with molded plastizote insole Total contact casting Healing sandal Cast boot

28. Treatment of infection Early incision and drainage Empirical broad-spectrum antibiotic. Vascular management of ischemia - Vascular supply should be assessed early before surgery intervention

29. Treat other medical co-morbidities DM is a multi-organ systemic disease. Multi-disciplinary approach.

30. Surgery Remove structurally deformed foot which my give rise to high pressure areas causing ulcers that do not heal with off loading technique or therapeutic foot wear Amputation- gangrene and ulcers with osteomyelitis Includes removal of infected bone or joint e.g: metatarsal head resection, partial calcanectomy, exostectomy, sesamoidectomy and digital arthroplasty

33. I & D, debridement, amputation Empirical regimen a) Mild mod infection - gram +ve - 1-2 weeks b) Severe and life threatening +ve, -ve, enterococci, anaerobic More than 2 weeks c) If osteomyelitis and have not been amputated: 2-8 weeks

34. Hypertrophic osteoarthropathy currently seen primarily in patients with diabetes who have peripheral neuropathy An abnormal vascular inflow producing bony resorption, bony weakening Etiology The traumatic etiology implies fracture or stress fracture without protective sensation->inherent motion applied to a nonimmobilized fracture. Neurotraumatic Neurovascular Hypertropic response

35. Amputation

36. 3 D’s D amned Nuisance - dt pain, gross malformation, recurrent sepsis, severe loss of function D ead - PVD, trauma, burns, frostbite D angerous - malignant tumours, potentially lethal sepsis, crush injury

37. Complication Early Breakdown of skin flaps Gas gangrene Late Skin- eczema, ulcer Muscle- improper use of prosthesis Artery- ulcer Nerve- pain & tender Phantom limb

38. Patient education

41. Patient education

43. References http://www.hrsa.gov/leap/patienteducation.htm www.emedicine.com Boon et al. Davidson’s principle and Practice of medicine. 20 th edition, Churchill Livingstone Elsevier 2006. page;844-846. Management of diabetic foot, CPG 2004 http://care.diabetesjournals.org/content/26/10/2848.full http://www.wagnergradeposter.com/012wagnerpic.jpg

44. Thank you =)