Diabetic Foot Infections:

Current Diagnosis and

Treatment Journal
Oleh :
I Gusti Ayu Nita Aksamalika
Ajie Firdaus Pradana
Pembimbing :
dr. Widiyatmiko Sp.OT

The Journal of Diabetic Foot

Complications, 2012; Volume 4,
Issue 2, No. 1, Pages 26-45
Authors : JJ Mendes and J Neves
1. Hospital de Santa Marta, Centro
Hospitalar de Lisboa Central EPE Rua
de Santa Marta, 50 1169-024 Lisboa
Portugal
2. Faculdade de Medicina de Lisboa
3. General Surgery Department, Hospital
de Santo Antnio dos Capuchos, Centro
Hospitalar de Lisboa Central EPE

Introduction
The world is facing a major epidemic of diabetes
mellitus (DM). There are an estimated 171 million
diabetic patients worldwide and this number is
expected to double by the year 2030. All of these
patients are at risk for developing a diabetic foot ulcer
(DFU). A DFU is any full-thickness wound below the
ankle in a diabetic patient, irrespective of duration.
Once the protective layer of skin is broken, deep
tissues are exposed to bacterial infection that
progresses rapidly. Patients with DFUs frequently
require amputations of the lower limbs and, in more
than half the cases, infection is the preponderant
factor.

Pathophysiology

Pathophysiology

Pathophysiology

Pathophysiology

Pathophysiology

Peripheral motor neuropathy

Clawing toes: hyperextension of MTT phalange joints, usually
accompanied by cavus foot and calluses on the dorsal surface of the
fingers and the plantar surface of the metatarsal head or the tip of
fingers.
Cavus Foot: under normal conditions the foot is shaped convexly due to
the longitudinal medial arch that is extended from the head of the first
MTT and the calcaneus; if this arch is abnormally high it produces an
abnormal distribution of weight loads, favoring the formation of calluses
in the forefoot and rearfoot .
Equinus Deformation: shortening of Achilles tendon (three muscles:
lateral, internal gastrocnemius and soleus), falling of plantar fascia and
facilitating abduct or adduct in the forefoot, beside the lost at the long
flexor and extensor tendons that produce dorsiflexion.
1st toe rigid: it is due to hardening of the first MTT phalange joint with
loss of dorsiflexion, resulting in excessive weight forces on the plantar
surface and callus formation.
Joint stiffness: The limitation of joint movement is produced by the
glycosylation of collagen and thickening of periarticular structures
(tendons, ligaments, joint capsule, etc.) which favors deformities and
plantar pressures, upsetting the biomechanics of the foot during walking
by limiting plantar flexion and promoting equinus foot

RISK FACTORS

Ulcer Classification

Ulcer Classification

Ulcer Classification

Clinical presentation
About 50% of patients with foot ulcers
due to DM present clinical signs of
infection. By definition, infection is
characterized by the presence of
purulent secretions or at least two of
the classic signs of inflammation
(erythema, hyperemia, edema, or
swelling and pain) but these data can
be masked by lack of the sensitivity in
the patient due to sensory neuropathy
or impaired immune response.

Diagnosis
History and physical examination
A proper investigation should be carried out in all
patientswith diabetes. A good history should include the
duration of DM, neuropathic and peripheral vascular
disease symptoms, previous ulcers or amputations and any
other complication of DM like retinopathy or nephropathy
Examination of ulcer
The location, size, shape, depth, base and margins of the
ulcer should be examined clinically.
Neurological testing
Laboratory investigations
The standard procedure involves measuring blood glucose
level and urine for glucose and ketones. Other
investigations like full blood count, blood urea, electrolytes,
and creatinine levels should be monitored regularly

Imaging
In case of diabetic foot, it is hard to assess
the depth of the ulcer especially when there
is pus and slough covering it. Also, it is hard
to determine the extent of deep infection as
the rubor of inflammatory response is
minimal in subfascial sepsis. X rays are
helpful to determine the depth of foot
ulceration and to assess presence of bone
infection or neuroarthropathy. Radiographs
may reveal bony erosions, fractures,
subluxation/dislocation of multiple joints,
osteosclerotic features or united fractures

Treatment

The treatment of foot ulcers in diabetic

patients varies constantly depending on
the severity of the ulcer and the presence
or absence of ischemia. However the
basic points of treatment are:
Debridement in case the ulcer presents
thick edges or necrotic tissue.
Reduction in overload pressure.
Complete rest of the foot (orthotics).
Treatment of the infection.
Local wound care.

Acute and Chronic Wound Healing

Physiology

Conclusion
DM is a global epidemic and the diabetic foot is one
of its most frequent and serious complications,
resulting in high social and economic costs.
According to the International Working Group on the
Diabetic Foot, a leg is lost to DM somewhere in the
world every 30 seconds, with infection accounting
for 50% of these cases.
The five-year mortality rate for diabetes-related
wounds and amputations is 68%, only surpassed by
lung and pancreatic cancer mortality rates 101. We
hope this hospital-based framework for diagnosing
and treating DFIs will help improve the hospital
management of DFIs and ultimately the prognosis of
these patients.