Diabetic Foot

Examination 1. Exposure - until the upper knee - examine both feet 2. Inspection a) Examination of the surrounding tissue - redness, pale, bluish and congested - oedema - scar - hard corns(h perkeratosis o!er the bon prominence, caused b pressure against the shoe) - soft corns(marcerated h perkeratosis lesion bet"een the toes not a#" pressure or friction) - callosit - fissure - cellulitis(raised, er thematous, edematous, painful and "arm) - abscess - scal - trophic changes(hair loss, brittle nails, skin shin , dr , loss of tissue turgor) - gangrenous changes - !eno$!aricosit - deformit i) fore foot% cla" toe ii) mid foot% ca!us foot, pes ca!us iii) hind foot% !algus heel - space bet"een the toes% an fungal infection b) Examination of the ulcer - single#multiple - site - si&e - shape - surrounding skin#tissue% redness, s"elling - margin - regular#irregular - "ell#ill$defined - edge - slopping% healing - punched out% non$healing - undermined% chronic process(p ogenic, '(, amaebic) - rolled% basal cell carcinoma - floor - pale, pink or red - health looking) - granulation tissue(sign of reco!er #healing) - sloughed(pale, ello"ish or greenish necrosed tissue) - discharge(serous, seropurulent, purulent) - exposed structures(bone, *oint, tendon, neuro!ascular bundle) - depth +. ,alpation - temperature - tenderness(of the ulcer and surrounding skin) - consistenc of surrounding skn - fixation

base - soft#firm#indurated(induration indicates fibrotic tissue underl ing) - smooth#irregular - fluctuant(abscess, pus) - contact bleeding - press at edge(milk for pus) -. .o!ement - toes - ankle /. 0euro!ascular a) motor - tone - po"er - reflex(knee and ankle *erks) b) sensor - light touch - pain - !ibration(first sensation to loss) - proprioception 1 look for 2gro!e and stocking3 distribution of sensor loss c) !ascular - pulses(popliteal, posterior tibialis and dorsalis pedis arteries) - capillar refilling Approach and Assessment 1. determine the cause - neuropath - ischaemic - combination 0europathic ulcer 1. dependant and pressure area% metatarsal head, heel and ball of the foot 2. +. -. /. 4. 5. 6. deformit (e.g.cla" foot) pink surrounding skin distended !ein callosities and fissures painless foot is "arm ulcer base% bleeds easil

7. palpable pulses 18. complications% - painless ulceration - infected ulcer - callosities - digital gangrene - 9harcoat3s *oint - 0europathic oedema

Ischaemic ulcer 1. distal part% medial surface of 1st metatarsal head, lateral surface of /th metatarsal head, tips of toes 2. gangrenous digits +. pale surrounding skin -. trophic changes /. skinn 4. painful to touch 5. cold foot 6. ulcer base% dull fibrotic and no bleed easil 7. "eak or absent pulses 18. complications% - painful ulceration - claudication - digital gangrene

1 !enous ulcer : bloated, edematous; usuall at medial malleolus 2. determine the stage(b .eggit$<agner 9lassification)

+. determine "hether is the lesion complicated b infection(cellulitis, abscess or osteom elitis) Characteristics of Diabetic Foot Infection 1. pol microbial - aerobes% =.aureus, =treptococci, 9oliform - anaerobes% (acteroides spp. 2. !er notorious(does not respect tissue plane : can in!ol!e "hole fascia) +. chronic in nature and relati!el resistant to treatment(healing process is abnormal) Meggit-Wagner Classification - based on depth of ulcer, presence osteom elitis and se!erit of gangrene =tage 8% 0o ulcer; present of risk factors(e.g. foot deformities, sensor neuropath , pre!ious >x.of foot ulcer, blind#partiall sighted) =tage 1% =uperficial ulcer, skin deep(full thickness of skin loss) =tage 2% Deep ulcer usuall "ith infection#cellulitis; no bone in!ol!ement =tage +% Infected deep ulcer "ith osteom elitis and abscess formation =tage -% ?lcer "ith gangrene of hindfoot(digits) =tage /% ?lcer "ith gangrene of forefoot Pathophysiology - multifactorial - + main causes% @) pol neuropath a. motor - "eakness of the intrinsic muscles imbalance bet"een the flexors and extensors deformities such as ca!us foot, cla" toes unusual and une!en pressure distribution repeated trauma b. sensor - loss of pain sensation una"are of noxious stimuli and unable to a!oid trauma continuous pressure on a particular pressure area(repetiti!e stress and high pressure in*ur hard callosities) - loss of proprioception sensation ataxia and prone to fall c. autonomic - reduced s"eating dr skin fissures and cracks portal of entr for microorganisms - loss of microcirculation autoregulation loss of normal h peraemic response needed to fight the infection () peripheral !ascular disease - compromised blood suppl poor immune mechanism and "ound healing - ischaemia de!italised tissue prone to infection 9) infection - high glucose content culture medium for microorganisms - high glucose content reduced chemotactic phagoc tosis of inflammator cells Investigations - - important in!estigations% i) "ound s"ab for microbiological examination A culture B sensiti!it (if abscess present aspiration) ii) random blood sugar or fasting blood sugar(assess blood sugar control) iii) foot x$ra (look for osteom elitis and charcot3s *oint) i!) ankle$brachial s stolic index(b Doppler u#s probe) - important esp. for ischaemic cause and serious infection - normal% 1.8

C 8.-/ is necessar for ulcer healing("ound healing "ill depend directl on the local blood flo") - D 8./% impending gangrene - D 8.+% amputation ma be needed other in!estigations% - blood culture - F(9 - (?=E - screen for other complications of diabetic mellitus -

Management - depends on the grading% @) Erade 8 - mainl proph laxis% a) foot care - foot h giene - "ear sock s or stockings - foot"ear should be "ell fitting "ith soft and pliable uppers - nails should be trans!ersel at the centre - dail inspection of accidental damage to feet - corns and callosities should be treated b a chiropodist - ne!er "alk bare$footed b) patient education - diabetic control(diet, compliance and follo"$up) - stop smoking( peripheral !ascular disease) c) correcti!e surger for deformities - to relie!e pressure o!er potential breakdo"ns areas () Erade 1, 2 and + 1. 9ontrol the infection a) local - abscess drainage and dressings - remo!ing mechanical forces(neuropathic ulcer can onl be healed if the mechanical forces are remo!ed)% i. strict bed rest ii. non "eight$bearing on crutches iii. total contact cast - in!aluable for the .x of plantar ulcer - for grade 1 and 2 ulcers - not used in ischaemic ulcers(made the condition "orse) - the ulcer is debrided and excess callus is remo!ed before the cast application - belo" knee plaster cast applied "ith minimal padding for a bon prominence - it pro!ides eFual distribution of forces along the plantar surface of the foot - a rigid compression dressing to control s"elling ans oedema - a protecti!e co!ering to compensate for the lack of sensation - surgical debridement of infected ulcer and necrotic tissue - surgical re!asculari&ation(!ascular reconstruction) of the ischaemic foot - skin graft(grade 1) - sometimes ma need local amputation(grade +) b) s stemic - antibiotics% - cloxacillin - metronida&ole(Flag l)

- gentamicin 2. 9ontrol the blood sugar - diet control - oral h pogl caemic agents(G>@) - insulin(ma shift from G>@ to insulin to ha!e proper blood sugar control) 9) Erade - and / - grade -% a) local amputation - if @(I C8.-/ and gangrene is dr and limited to distal portion of toe b) ra amputation - if gangrene is "et and progressi!e c) belo"$knee, through$knee or abo!e$knee amputation - if @(I has not been high enough for distal amputation - grade /% - local pocedures not adeFuate - belo"$knee, through$knee and e!en abo!e$knee amputation as indicated b !ascular status