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Diabetic Foot

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Learning outcomes

WELCOME TO THE DIABETIC FOOT MODULE!


Nice pic, but why is this module
important?

Epidemiology
Pathophysiology
Section one quiz
Assessment
Section two quiz
Management
Section three quiz
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Page 1 of 67

Well, in 2007, 246million


people aged 20 - 79 years were
diagnosed with diabetes mellitus
a global epidemic affecting 6%
of the adult population.
25% of these develop foot
problems...thats 61.5 million
diabetic feet!
And, worryingly, the prevalence
of diabetes mellitus is expected
to reach 333 million by 2025.

The foot of a diabetic patient showing


extensive tissue necrosis and infection

For information on the


authors and reviewers
click here

How should you study this module?


Title slide
How you should
study this module
Learning outcomes
Epidemiology
Pathophysiology
Section one quiz
Assessment
Section two quiz
Management
Section three quiz
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Page 2 of 67

1. We suggest that you start with the learning objectives and try
to keep these in mind as you go through the module slide by
slide.
2. Print out the mark sheet.
3. As you go along, write your answers to the questions on the
mark sheet as best you can before looking at the answers.
4. Award yourself marks as detailed on the mark sheet: one
mark for each keyword (shown in the red text) in the short
answer questions and for every correct answer in the
True/False questions.
5. Repeat the module until you have achieved a mark of > 80%
(65/81)
6. Finish with the formative multiple choice questionnaire to
assess how well you have covered the materials as a whole.
7. You should research any issue that you are unsure about.
Look in your textbooks, access the on-line resources indicated
at the end of the module and discuss with your peers and
teachers.
8. Finally , enjoy your learning! We hope that this module will be
enjoyable to study and complement your learning about
diabetic foot from other sources.

Learning Outcomes
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How you should
study this module
Learning outcomes
Epidemiology
Pathophysiology
Section one quiz
Assessment
Section two quiz
Management

By the end of the module, you should be able to:


1.
Discuss the global burden of the diabetic foot in
both the developing and developed world
2.
List the causes of diabetic foot ulceration then
fully assess for each one and their complications;
using bedside examinations, blood tests,
microscopy and radiology
3.
Discuss the management of diabetic foot ulcers
using
i. mechanical intervention (debridement, dressing and
cast application)
ii. invasive treatment (larvae, antimicrobials and
amputation)
iii. analgesia

Section three quiz


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4.

Offer advice to diabetic patients on proper foot


care and footwear for prevention of foot problems

Epidemiology 1
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How you should
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So how many people with diabetes are there?


Here are recent estimates of the disease burden due to diabetes and
projections for the future.

2003

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Epidemiology
Pathophysiology
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Management
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Page 4 of 67

Europe

Africa

Europe

Africa

872 million

667 million

863 million

1107 million

621 million

295 million

646 million

541 million

48.4 million

7.1 million

65 million

19million

7.8 %

2.4 %

7.8 %

4.3 %

Population
Total
Adult
(20-79 yrs)

2025

Diabetes
No. of people
(20-79 yrs)
Prevalence
(20-79 yrs)

Source: International Diabetes Federation and The international Working Group on Diabetes
joint publication 2006.

Epidemiology 2
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Thats a lot! How many of these get foot ulcers?


Developed countries: 15% of people with diabetes get ulcers at least once in
their lifetime
Developing countries: the prevalence is even higher at 20%.
...and does amputation use vary from place to place? Yes!...see below;
Incidence of minor and major amputations per 1000 people with diabetes

Epidemiology

Incidence
per 1000

Population

Year

Mauritius

680

Hospital-oriented

1998-2002

Tanzania

400

Hospital-oriented

2002

Croatia

6.8

Hospital-oriented

2002

Section three quiz

UK

2.6

Regional

1998

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The Netherlands

3.6

Nationwide

1991-2000

Pathophysiology
Section one quiz
Assessment
Section two quiz
Management

Source: International Diabetes Federation and The international Working Group on Diabetes joint
publication 2005.

Epidemiology Quiz
Title slide

According to the above data;


Click the box for the
correct answer

How you should


study this module
Learning outcomes

1.

Which region has the most people with


diabetes?

2.

Which region will see the greatest


increase in diabetes prevalence by
2025 ?

3.

Which region has the greatest disease


burden due to diabetic foot ?

Epidemiology

Pathophysiology
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Section two quiz
Management

Section three quiz


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Page 6 of 67

Epidemiology 3
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How does the diabetic foot affect individuals


and society?

Diabetic foot ulcers and their complications


(explained later) are often painful. Patients often
become dependent on others for mobility.
As a result, patients suffer a loss of autonomy and
reduced social function, making depression
common.

The cost of diabetic foot management is 12-15% of


the total healthcare budget for diabetes in developed
countries. This figure may as high as 40% in
developing countries*. These figures do not account
for the cost of the loss of potential working members
to the economy and the social costs of the inability to
support a family.

Epidemiology
Pathophysiology
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Management
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Page 7 of 67

*IDF/IWG joint publication on diabetic foot.

Pathophysiology
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Epidemiology
Pathophysiology

Well those diabetic feet are everywhere and causing


chaos! If were going to stop them, I would first like to
know how diabetic foot ulcers occur
Diabetic foot ulcers may have multiple causes, the
prominent ones being;

Section one quiz


Assessment

A.

Peripheral neuropathy (nerve damage)

B.

Peripheral vascular disease (poor pedal blood


supply)

C.

Trauma

Section two quiz


Management
Section three quiz
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Page 8 of 67

i. Acute: any injury to the foot such as burns or cuts


ii. Chronic: due to foot deformities (changes of foot shape
that lead to ill-fitting shoes and, thereby, ulceration)

Neuropathy

Pathophysiology

Title slide

Neuropathy

How you should


study this module
Learning outcomes

Motor

Sensory

Autonomic

Epidemiology
Pathophysiology
Section one quiz

Muscle wasting
Foot weakness
Postural deviation

Proprioception,
Unawareness
of foot position

Assessment
Section two quiz

nociception

Management
Section three quiz
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Page 9 of 67

Deformities, stress
and shear pressures

Trauma

Stress on bones & joints


Plantar pressure

Callus formation

Reduced
sweating

A-V Shunt* open


Permanent

Dry skin

Increase foot
Blood flow

Fissures and
cracks

Ulcer

*Shunts: blood vessels that bypass capillaries and lead directly from arteries to veins

Bulging foot veins,


Warm foot

Infection

Pathophysiology

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Learning outcomes
Epidemiology
Pathophysiology
Section one quiz
Assessment
Section two quiz

Peripheral Arterial Disease


Then how are blood vessels
affected?
High blood sugar expedites
artherosclerosis giving peripheral
vascular disease (reduction of blood
supply to the foot).
The delivery of essential nutrients
and oxygen to the foot is
compromised leading to anaerobic
infections and tissue necrosis.

Peripheral arterial disease

Artherosclerosis
narrows or blocks
the arterial lumen

Foot ischaemia
Foot ulcer

Necrosis/ Gangrene

Management
Section three quiz
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Page 10 of 67

Ischaemic toes due to


artherosclerosis

Infection

Artheroma plaque
narrowing the arterial
lumen

Pathophysiology

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Epidemiology
Pathophysiology
Section one quiz

Trauma
Dont people with diabetes feel trauma before it
reaches ulceration stage? No- thats the
problem!
Acute trauma: abrasions and burns occur often due
to the absence of nociception. Poor wound
healing makes ulcerations more likely occur.

Assessment
Section two quiz
Management
Section three quiz
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Page 11 of 67

Chronic trauma: reduced motor function results in a


high arch. Together with decreased
proprioception, this creates classical deformed
foot shapes (explained later). These result in
bony prominences which, when coupled with
high mechanical pressure on the overlying skin,
results in ulceration.

End of Section 1
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How you should
study this module

Well done!
You have come to the end of the first section

Learning outcomes
Epidemiology
Pathophysiology
Section one quiz
Assessment
Section two quiz
Management
Section three quiz
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Page 12 of 67

We suggest that you answer Question 1 to 4 to


assess your learning so far. Please remember to
write your answers on the mark sheet before
looking at the correct answers!

Section 1 Quiz
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How you should
study this module

Question 1: write T or F on the answer sheet. When you have


completed all 5 questions, click on the boxes and mark your
answers.

Learning outcomes
Epidemiology
Pathophysiology

a)

Diabetic foot is a global health problem

b)

The prevalence of diabetes is falling

c)

The incidence of foot ulcers in people with


diabetes is higher in developed than developing
countries

Section one quiz


Assessment
Section two quiz
Management
Section three quiz
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Page 13 of 67

d
d)

Diabetic foot amputation is commoner in


developing countries than developed countries

Section 1 Quiz
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How you should
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Question 2: write T or F on the answer sheet. When you have


completed all 4 questions, click on the boxes and mark your
answers.

Learning outcomes
Epidemiology
Pathophysiology
Section one quiz
Assessment
Section two quiz
Management

a) Diabetic foot problems result in a higher


cost to the economy in developing than
developed countries
b) Depression is common in diabetic foot
patients

Section three quiz


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Page 14 of 67

c) Wound healing is slower in diabetes


d) Artherosclerosis is common in diabetes
patients

a
b
c
d

Section 1 Quiz
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Learning outcomes
Epidemiology

Question 3: The 4 main causes of diabetic foot ulcers


are; write the answers in your mark sheet.

a)

Peripheral neuropathy

b)

c)

Peripheral arterial disease

d)

Pathophysiology
Section one quiz
Assessment
Section two quiz
Management
Section three quiz
Information
sources

Click here for the


answers

Section 1 Quiz
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How you should
study this module

Question 4: Study this flow chart and list 4 factors that predispose to
diabetic foot ulceration. Write your answer in your mark sheet

Click here for


the answers

Neuropathy

Learning outcomes
Epidemiology

Motor

Sensory

Autonomic

Pathophysiology
Section one quiz
Assessment

Muscle wasting
Foot weakness
Postural deviation

Proprioception,
Unawareness
of foot position

Section two quiz


Management

nociception

Section three quiz


Information
sources
Page 16 of 67

Deformities, stress
and shear pressures

Trauma

Stress on bones & joints


Plantar pressure

Callus formation

Reduced
sweating

A-V Shunt* open


Permanent

Dry skin

Increase foot
Blood flow

Fissures and
cracks

Ulcer

*Shunts: blood vessels that bypass capillaries and lead directly from arteries to veins

Bulging foot veins,


Warm foot

Infection

Assessment
Title slide
How you should
study this module
Learning outcomes
Epidemiology
Pathophysiology
Section one quiz
Assessment
Section two quiz
Management
Section three quiz
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Page 17 of 67

How do we predict how bad a diabetic foot is then?


Foot assessment needs to be undertaken in all people with
diabetes to evaluate the individuals risk of foot
complications and hence plan management.
It can be undertaken by a podiatrist, junior doctor,
specialised diabetes nurse or other trained nurses.
The aim of the assessment is to examine each pathological
cause that creates ulcers:
1) peripheral neuropathy
2) peripheral arterial disease
3) structural

But how do you assess the diabetic foot? Let me


guess. As always start with the history and then the
examination for each cause ?- Bingo!

Assessment

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Epidemiology
Pathophysiology
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Page 18 of 67

Peripheral Neuropathy
History

burning, tingling, numbness of the foot


and nocturnal leg pain indicate
cutaneous sensory deficits

Note that in ~35% of patients who are


asymptomatic, neuropathy can be
detected by examination
Examination

Inspect deformities such as claw toes,


hair loss, muscle atrophy and a high
medial longitudinal arch (giving
prominent metatarsal heads)

Test for reduced power and reflexes that


are evidence of muscular motor deficits.

Test sensation by skin pinprick


(spinothalamic tracts), proprioception
and vibration (dorsal columns)

Claw toes

Prominent metatarsal
heads and an ulcer

Assessment

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Monofilament for pressure sensation (pinprick sense)

Epidemiology
Pathophysiology
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Management
Section three quiz
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Page 19 of 67

Place a 10g nylon Semmes-Weinstein


monofilament at a right angle to the skin
Apply pressure until the monofilament
buckles, indicating that a specific
pressure has been applied.
Inability to perceive the 10g of force
applied by the monofilament is
associated with clinically significant
large fibre neuropathy and an increased
risk of ulceration (sensitivity of 66 to
91%)
Test 4 plantar sites on the forefoot
(great toe and the base of 1st, 3rd and 5th
metatarsals ) to identify 90% of patients
with an insensate foot.

Monofilament test

Tuning Fork (vibration)

Assessment

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Epidemiology

Pathophysiology
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Apply a vibrating 128 Hz tuning fork


to the bony prominence of the big
toe
If the patient cannot feel the
vibration, gradually move the fork
upwards
The sensitivity of this test for
demonstrating a deficit is ~53%
A biothesiometer is a portable
device that measures the vibration
perception threshold. A vibration
threshold of more than 25V has a
sensitivity of 83%.

Tuning fork
test

Either an abnormal 10g monofilament test or a vibration


threshold of more than 25V predicts foot ulceration with
a sensitivity of 100% , hence the rationale for combining
these two tests in clinical practice.

Assessment

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Learning outcomes
Epidemiology
Pathophysiology

Peripheral Vascular Disease (PVD)


So how do we know how well the blood is flowing?
History : claudication (calf pain after walking a specific distance) that
is relieved by rest. However this is uncommon in people with diabetes
due the concomitant neuropathy.
Examination: Palpate the foot for temperature (cool in PVD); palpate
the dorsalis pedis pulse and, if absent, the posterior tibial pulse. Test
for Bergers angle (at which leg turns white) and reactive hyperaemia
(leg turns bright red on declining back to the ground).

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Palpation of the dorsalis pedis pulse

Palpation of the posterior tibial


pulse

Assessment

Investigations: ankle brachial pressure index

Title slide

Measure the blood pressure (BP) in the


How you should
arm using a sphygmanometer
study this module Measure the blood pressure in the foot.
Place a BP cuff around the calf and detect
Learning outcomes
the dorsalis pedis pulse using a small
hand-held doppler. Inflate the cuff and
Epidemiology
slowly deflate until the pulse appears.
Pathophysiology
The ankle brachial pressure index (ABPI) is
the ratio of the ankle systolic pressure to
Section one quiz
brachial systolic pressure.
Assessment

Section two quiz


Management
Section three quiz
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Page 22 of 67

ABPI is usually >1 but in the presence of


peripheral vascular disease is <1. Normal
ABPI effectively excludes significant
arterial disease in >90% of limbs.

Doppler being used to detect


the dorsalis pedis pulse

Absence of pulses and an ABPI of <1 confirms significant


ischaemia. An exception is in medial artery calcification, in
which the ABPI can be falsely elevated due to the
simultaneously lower blood pressure (BP) in the upper limb.

Assessment

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Epidemiology
Pathophysiology
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Structural Abnormalities and Deformities


Structural abnormalities and deformities lead
to bony prominences which are associated
with high mechanical pressure on the
overlying skin.
This results in ulceration, particularly in the
absence of a protective pain sensation and
when shoes are unsuitable.
Ideally, the deformity should be recognised
early and accommodated in properly fitting
shoes before ulceration occurs.

Callus on plantar surface

Common abnormalities / deformities include:


i.
ii.
iii.
iv.
v.
vi.

Callus
Bunion
Hammer toes
Claw toes
Charcot foot
Nail deformities

Note: It is vital to inspect the patients


shoes as part of the assessment!
Bunion on the medial
border of the foot

Assessment

Some Common Foot Deformities

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Epidemiology
Pathophysiology
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Claw toes

Section two quiz


Management
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Nail deformity

Charcot foot
deformity

Assessment

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Epidemiology
Pathophysiology
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Ulcers
Pre-ulcer assessment all done! What about after an
ulcer has developed?
Several foot ulcer classifications
have been proposed although none
is universally accepted.
The simplest classification is based
on the underlying pathogenesis:
neuropathic, ischaemic or
neuroischaemic.
It is vital to carefully monitor the
progress of an ulcer once one has
developed.
The University of Texas system
shown on the next slide can be used
to predict outcome by grading
wound depth and presence of
infection and/or ischaemia.
However there is no measure of
neuropathy.

A neuropathic ulcer on
the sole of the foot

Assessment

University of Texas system for classification of ulcers


Ulcer Grade ( depth )

Title slide
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Learning outcomes
Epidemiology

Ulcer
stage

I.

II.

III.

Pre / postulcerative
lesion completely
epethelialised

Superficial
lesion, not
involving tendon,
capsule or bone

Wound
penetrating to
tendon or
capsule

Wound
penetrating to
bone or joint

Pre / postulcerative
lesion with
Infection

Superficial
lesion, not
involving tendon,
capsule or bone
with Infection

Wound
penetrating to
tendon or
capsule with
Infection

Wound
penetrating to
bone or joint
with Infection

Pre / postulcerative
lesion with
ishaemia

Superficial
lesion, not
involving tendon,
capsule or bone
with ischaemia

Wound
penetrating to
tendon or
capsule with
ishaemia

Wound
penetrating to
bone or joint
with ishaemia

Pre /postulcerative
lesion with
infection and
ishaemia

Superficial
lesion, not
involving tendon,
capsule or bone
with infection
and ischaemia

Wound
penetrating to
tendon or
capsule with
infection and
ishaemia

Wound
penetrating to
bone or joint
with infection
and ishaemia

Pathophysiology
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Assessment

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Epidemiology
Pathophysiology
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Infected Ulcers
How do you know if the ulcer is infected then?
Assessing foot ulcers for the presence of infection is vital. All
open wounds are likely to get colonised with microorganisms,
such as Staphylococcus aureus, and not necessarily infected.
Therefore, the presence of infection needs to be defined
clinically rather than microbiologically.

Signs suggesting
infection include;
1. purulent
secretions
2. presence of friable
tissue
3. undermined edges
4. foul odour
An infected ulcer

Assessment

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Epidemiology
Pathophysiology
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Infected Ulcers: Investigations


Simple investigations include:
Tissue specimens or material obtained from the bottom of a
wound for gram staining and culture for microbial sensitivity.
Aspiration of material for culture is better than taking a swab
which is prone to contamination.
Full blood count, urea and electrolytes, inflammatory markers
(WCC, ESR and CRP) for assessing severity of infection
Plain X-ray of the leg for signs of bone damage, presence of
foreign body, or gas in soft tissue (gas gangrene)
More advanced radiology involves:
Technetium bone scan and MRIs may be necessary in some
patients to define underlying bony involvement
Invasive investigations include:
Bone biopsy, as the gold test for diagnosing osteomyelitis.
Arteriography using contrast dye can be used to visualise leg
ischaemia

End of Section 2
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Learning outcomes

Well done!
You have come to the end of the second section

Epidemiology
Pathophysiology
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Section two quiz
Management
Section three quiz
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We suggest that you answer Questions 5 to 9 to


assess your learning so far. Please remember to
write your answers on the mark sheet before
looking at the correct answers!

Section 2 Quiz
Title slide
How you should
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Question 5: List the 3 components of diabetic foot


assessment. Write your answer in your mark sheet

Learning outcomes
Epidemiology
Pathophysiology
Section one quiz
Assessment
Section two quiz
Management

1) ..
2) ..
3) ..

Section three quiz


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Click here for the


answers

Section 2 Quiz
Title slide
How you should
study this module

Question 6: Write T or F on the answer sheet. After


completing all 5 questions, click on the boxes and mark
your answers.

Learning outcomes
Epidemiology

a)

A high medial longitudinal arch and prominent


metatarsal heads are signs of ischaemia

b)

The tuning fork and biothesiometer are used for


assessing pressure sensation

c)

Ankle brachial pressure index is the ratio of ankle


systolic pressure to brachial diastolic pressure

d)

A doppler can be used to confirm the presence of


pulses but cannot quantify the vascular supply

e)

Bone biopsy is the gold standard for diagnosing


osteomyelitis

Pathophysiology
Section one quiz
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Section two quiz
Management
Section three quiz
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Section 2 Quiz
Title slide
How you should
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Question 7: Identify these clinical images. Write your answer in your


mark sheet

Learning outcomes
Epidemiology

Click here for the


answers

Pathophysiology
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Section two quiz

Management
Section three quiz
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Page 32 of 67

3
4

Section 2 Quiz
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How you should
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Question 8: List 5 common foot deformities found in


association with diabetic feet. Write your answers on
the mark sheet.

Learning outcomes
Epidemiology
Pathophysiology
Section one quiz
Assessment
Section two quiz
Management
Section three quiz
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I.
II.
III.
IV.
V.

Click here for the


answers

Section 2 Quiz
Title slide
How you should
study this module

Question 9: Fill in the blanks in the University of Texas grading and


staging table. Write your answer in your mark sheet
Ulcer Grade ( depth )

Learning outcomes

I.

II.

III.

Pre / postulcerative
lesion completely
epethelialised

Superficial
lesion, not
involving tendon,
capsule or bone

Wound
penetrating to
tendon or
capsule

Wound
penetrating to
bone or joint

Epidemiology
Pathophysiology
Section one quiz
Assessment
Section two quiz

Ulcer
stage

Superficial
lesion, not
involving tendon,
capsule or bone
with Infection

Management
Section three quiz
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Pre / postulcerative
lesion with
Ishaemia

Pre /postulcerative
lesion with
Infection and
Ishaemia

Wound
penetrating to
bone or joint
with Infection
Wound
penetrating to
tendon or
capsule with
Ishaemia

Superficial
lesion, not
involving tendon,
capsule or bone
with Infection
and Ischaemia

Wound
penetrating to
tendon or
capsule with
Infection and
Ishaemia

Wound
penetrating to
bone or joint
with Infection
and ishaemia

Management
Title slide
How you should
study this module

Ok, so now we know the extent of the problem, how it


occurs and how to assess for it. Now what do we do
about it?

Learning outcomes
Epidemiology
Pathophysiology
Section one quiz
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Section two quiz
Management
Section three quiz
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Page 35 of 67

General measures
Managing diabetes and its complications requires a
multidisciplinary approach because
optimum glycaemic control is key in reducing all
complications
cardiovascular risk factors such as smoking,
dyslipidaemia and hypertension should be
addressed to reduce risks of PVD, acute coronary
syndrome and chronic renal failure
education of patients on proper foot care and on the
importance of seeking medical advice early is very
important

Management

The Normal Foot

Title slide

If a patient with diabetes has normal feet do we need to worry?...YES!

How you should


study this module

Your aim is to keep the foot normal. Key elements are:


wearing the correct footwear
the diagnosis and prompt treatment of foot problems that are common in the general
population including people without diabetes.

Learning outcomes
Epidemiology
Pathophysiology
Section one quiz
Assessment
Section two quiz

Good shoe guide:


Toe box should be sufficiently long, broad and deep to accommodate the toes without
pressing on them, with a clear space between the apices of the toe the toe box
Shoes should be fasten with adjustable lace, strap or Velcro high on the foot in order to hold
foot firmly inside the shoe and thus reduce frictional forces when the patient walks
The heel of the shoe should be less than 5 cm to avoid weight being thrown forward into
metatarsal heads
The inner lining of shoe should be smooth
Stocking or socks should always be worn to avoid blisters

Management
Section three quiz
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Good pairs of shoes for men and women

An example of a bad
shoe type

Management

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Diagnosing and treating common foot problems


Most people in this stage will be able to cut their
own toe nails. However specific nails and other
minor foot problems will need treatment from
the podiatrist. These are the most common
conditions:
Onychogryphosis (rams horn nail); regular
debulking by a podiatrist
Onychocryptosis (ingrowing toe nail); removal
of the offending nail splinter and filing of the
ragged edge by a podiatrist
Involuted toe nail; clearance of the sulcus with
a Blacks file (specially design for it)
Onychomycosis; reduce bulk of the nail at
regular intervals, treat with antifungals
Tinea pedis (athletes foot); treat with topical
antifungals (e.g canesten).
Verrucae (warts); treat by cryotherapy. Most
resolve within 2 years.
Corns; removal by a podiatrist.

Nail cutting

Athletes foot

Management

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The At-Risk Foot


And if neuropathic or ischaemic and/ or deformities
are present? - This foot is susceptible to ulcers, so...
Deformities should be accommodated in
properly fitting footwear. Special footwear
will be needed if the deformity is severe.
Some specific deformities need special
management;
Clawed toes need a shoe with a wide,
deep, soft toe box to reduce pressure on
the dorsum of the toes. Extra depth
shoes to protect the apices of the toes
Prominent metatarsal heads: an extra
depth stock shoe with a cushioning insole
may suffice
Callus: Is the most important pre-ulcerative
lesion in this stage. It should be regularly
and sufficiently remove by a podiatrician
with a scalpel.
Dry skin and fissure: treat with an
emolient (E45 or calmurid cream), reduce
fissure margins with scalpel

Callus removal

Management

Peripheral Arterial Disease (PAD)

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If PAD is evident:
address cardiovascular
risk factors
smoking
dyslipidaemia
hypertension

treat with oral aspirin


75mg OD
seek advice from a
vascular surgeon if
available

Palpation of the dorsalis pedis pulse

Note: Vascular assessment is also needed before


cutting nails/calluses to ensure that wound healing
is adequate.

Management

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Foot Deformities
How should we advise patients that get
deformities?
Provide patients with the following
information:
Never walk bare footed
Visit a podiatrist regularly if you have
callus
Never try to remove corns or callus by
yourself
Prevent dryness in your feet by using
creams
Be careful not to burn your feet
Shake out loose pebbles or grit before
you put on your shoes
Run a hand around the sides of the
shoes to detect rough, worn places
Repair or replace worn out shoes

Claw toes

Management

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Ulcers due to Ischaemia


Its an ulcer..what now!?-Dont panic, be methodical.
Treatment of diabetic foot ulcers largely depends on the
underlying causes: ischaemia, neuropathy or a combination of
both. Treatment approaches for ischaemia include:
Medical: reduce cardiovascular risk
factors (see above)
Surgical: revascularisation to achieve
timely and durable wound healing is
sometimes necessary. Patients with
supra-inguinal (aorta-iliac) disease may be
amenable to angioplasty (+/- stenting),
with good long-term results being
achieved at a low risk. Open bypass
surgery may be considered for those
patients who do not have an endovascular
option.

Ischaemic necrosis of a
toe and an extensive
plantar ulcer

Management

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The key to treatment here is to redistribute plantar


pressure.

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Page 42 of 67

Ulcers due to Neuropathy

The best method is some form of cast


(see later) .
If not available, temporary ready-made
shoes with a plastozote insole such as
Drushoe can off-load the site of
ulceration. Alternatively, weight-relief
shoes and felt pads may also be used.
Other weight-relieving measures such as
the use of crutches, wheelchairs and
zimmer frames should be encouraged.
Heeled ulcers also need off-loading by
foam wedges, heel protector splints or
rings.

The common site for


a neuropathic ulcer

When the neuropathic ulcer has healed, it is vital that the patient is
fitted with a cradled insole and bespoke shoes to prevent recurrence.

Management

Offloading Pressure: Casts

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These cast things sound useful...what are


they?
Various casts are available and all aim to relieve plantar
pressure. Their use is governed by local experience and
expertise
Air cast (walking brace)
A bivalved cast with the halves joined together with Velcro
strapping. The cast is lined with 4 air cells which can be
inflated with a hand pump to ensure a close fit. The cast
can be removed easily by patients to check their ulcers
and before going to bed.

An air cast

Scotch cast boot


A simple, removable boot made of stockinette, soffban
bandage, felt and fibreglass tape.
Total contact cast
It is a close-fitting plaster of paris and fibreglass cast
applied over minimum padding. It is very efficient method
of redistributing plantar pressure, and should be reserved
for plantar ulcers that have not responded to other casting
treatments.
A scotch cast boot

Casts: Some Precautions

Management

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Casts should be removed every week for wound inspection and


then renewed. Once the ulcer is healed, the patient should
be assessed for cradled insoles and bespoke shoes.

Epidemiology

Cast problems to be aware of:

Pathophysiology

Iatrogenic lesions (rubs, pressure sores, infections) which


often go undetected

Cast are often heavy and uncomfortable and reduce the


patients mobilty

Patients may not drive a car in a cast

The leg may develop immobilisation osteoporosis

Danger of fracture and the development of a Charcot foot


when coming out of a cast if patient walks too far too soon

A few patients develop a cast phobia and will not wear them

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Management

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Wound Debridement
What can we do to treat the ulcer?
In both isacheamic and neuropathic ulcers, treatment is based on debridement of the
wound and dressing application.

Debridement is the removal of necrotic


and dead tissue in order to enhance
healing.
Debridement is undertaken to:
Remove callus in neuropathic foot to
lower plantar pressure
Assess the true dimension of the
ulcer
Drain exudate and remove dead
tissue to render infection less likely
Take a deep swab for culture
Encourage healing and restore a
chronic wound to an acute wound

Forcep and a scalpel is the


usual technique by cutting
away of all slough and nonviable tissue.

Management

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Wound Debridement using maggots (larvaetherapy)

The larvae of the green bottle fly (which feed on dead flesh) are
sometimes used to debride ulcers, especially in the ischaemic
foot. Only sterile maggots obtained from a medical maggot farm
should be used!
Maggots produce a mixture of proteolytic enzymes that breakdown
slough and necrotic tissue which they ingest as a source of
nutrients. During this process, they also ingest and kill bacteria
including antibiotic resistant strains.
As a result of their wound cleansing activity, the application of
maggots has been found to reduce wound odour, and it has also
been reported that their presence within a wound stimulates the
formation of granulation tissue.
Contra-indications to maggot therapy:
Free range maggots should not be introduced into wounds that
communicate with the body cavity or any internal organ
They should not be applied to wounds that have a tendency to
bleed easily or contain exposed large blood vessels
They should not be applied to patients with clotting disorders, or
individuals receiving anticoagulant therapy unless under
constant medical supervision in a health facility.

Management

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Larvaetherapy Preparations
Maggots are available in 2 forms.
1. Free Range maggots
applied directly to the wound
roam freely over the surface seeking
out areas of slough or necrotic
tissue
generally left on wound for a
maximum of 3 days.
2. BioFOAM Dressing
Maggots enclosed in net pouches
containing pieces of hydrophilic
polyurethane foam
dressing is placed directly upon the
wound surface
BioFOAM Dressing can be left for up
to 5 days then the wound is
reassessed.

BioFOAM dressing with


maggots inside

Management

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Wound Dressings
A sterile, non-adherent dressing should cover all open diabetic foot lesions
to protect them from trauma, absorb exudate, reduce infection and promote
healing.
Dressings should be lifted every day to ensure that problems or
complications are detected quickly, especially in patients who lack
nociception.
Additional approaches include
Skin graft:
A split-skin graft may be harvested and applied to the ulcer to speeds healing of
the ulcer which if has a clean granulating wound bed

Vacuum-Assisted closure (VAC) pump:


This is an innovative measure to close diabetic foot wounds. It applies gentle
negative pressure to the ulcer via a tube and foam sponge which are applied to
the ulcer over a dressing and sealed in place with a plastic film to create a
vacuum. Exudate from the wound is sucked along the tube to a disposable
collecting chamber. The negative pressure improves the vascularity and
stimulates granulation of the wound.

New Developments

Management

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Epidemiology

Are there any new interesting aids for wound healing? Yes, three here;
Hyperbaric oxygen therapy: Poor tissue oxygenation with diabetic
microangiopathy reduces wound healing. Therefore hyperbaric oxygen
therapy (HBOT) would theoretically aid in faster wound healing, there is
however little evidence for this at present.

Growth factor therapy: Recombinant platelet derived growth factor (PDGF)


was the first growth factor approved by the Food and Drug Administration
(FDA) for the treatment of lower extremity diabetic neuropathic ulcers that
extend into the subcutaneous tissue and have adequate blood supply. PDGF,
applied as a gel , theoretically acts to enhance granulation tissue formation
and facilitate epithelialisation . It may be useful in small, low-grade so may
have a role in chronic neuropathic ulcers that are refractory to conventional
therapy but there is no evidence to support this theory.

Bioengineered human dermis transplantation: Dermagraft is a cultured


human dermis produced by seeding dermal fibroblasts on a biodegradable
scaffold. After culture, a living dermal tissue is created which can later
support the formation of an epidermis. Furthermore, dermatograft can
generate growth factors, cytokines, matrix proteins and glycosaminoglycan,
thus aiding the healing process. There have been a limited number of trials
have confirmed the efficacy of dermagraft in healing chronic ulcers in a
significantly shorter time.

Pathophysiology
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Management

Infected Ulcers - Antibiotics


It appears infected...which antibiotics to use?

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Treating infected ulcers:

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Ensure the previously described physical wound management techniques are used.
The initial antibiotic regime is usually selected empirically based upon clinical
experience and local preferences; cover of +cocci is essential as they are the usual
culprits of infection as they thrive cutaneously. Antibiotics are modified on the basis
of clinical response and and wound culture / sensitivity results. Good examples
include;

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Oral antibiotics

Perenteral antibiotics

Penicillin V OR co-amoxiclav +/-

Benzylpenicillin +/-

Flucloxacillin
Ciprofloxacillin
Cephalexin
clindamycin

Flucloxacillin
Imipenem-cilastin
Ampicillin-sulbactam
Cefuroxime
Metronidazole ( for anaerobes )

Management
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For mild infections, 7-10 day course is usually sufficient. Severe infections
may need up to 2-3 weeks of treatment.

The Charcot Foot

Management

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And when the bone gets infected?


Lastly, treating underlying osteomyelitis is an
important therapeutic challenge. Presence of
osteomyelitis warrants long-term treatment of
at least 4 6 weeks duration with antibiotics
that penetrate well into bone such as
fluoroquinolones, clindamycin or fusidic acid.
Surgical ressection still remains the most
definitive treatment for osteomyelitis especially
for patients not responding to antibiotics.

An infected
ulcer
draining
pus

Treating Charcots neuro-osteoarthropathy


Charcot foot refers to bone and joint destruction that occurs in the neuropathic foot
or rarely just the toe. It can be divided into three phases:

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Acute onset;

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Bony destruction / deformity;


Stabilistion;
1.

Acute onset

Characterised by unilateral erythema and oedema and the foot is at least 2C


hotter than the contralateral foot. About 30% of patients may complain of pain or
discomfort which is rarely severe. X-ray may be normal, but a technnetium
methylene diphosphonate bone scan will detect early evidence of bony destruction.

Management

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The Charcot Foot - 2


Patients awaiting bone scan should be treated as if the diagnosis has been
confirmed;
Initially the foot is off-loaded and immobilised in a non-weight-bearing cast to prevent
deformity. After 1 month, a total-contact cast is applied and the patient may mobilise
for brief period. However, the patient is given crutches and encouraged to keep
walking to a minimum.
If given early, these measures can prevent bony destruction. Bisphosphonates are
potent inhibitors of osteoclast activation and may also be used in this phase.
2.
Bony destruction
Clinical signs are swelling, warmth, a temperature 2C greater than the contralateral
foot and deformities including the rocker-bottom deformity and medial convexity.
X-ray reveals fragmentation, fracture, new bone formation, subluxation & dislocation.
The aim of treatment is immobilisation until there is no X-ray evidence of continuing
bone destruction and the foot temperature is within 2C of contra lateral foot.

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A photo showing a charcot foot


with an ulcer on the sole

Management

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The Charcot Foot - 3


3.
Stabilisation
The foot is no longer warm and red. There may still be oedema but the difference
in skin temperature between the feet is less than 2C. the X-ray shows fracture
healing, sclerosis and bone remodelling.
The patient can now progress from a total-contact cast to an orthotic walker, fitted
with cradled moulded insoles if necessary to accommodate a rocker-bottom or
medial convexity deformity. Cautious rehabilitation should be the rule, beginning with
a few short steps in a new footwear.

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Finally, the patient may progress to bespoke footwear with moulded insoles as the
rocker-bottom charcot foot with plantar bony prominence is a site of very high
pressure. Regular reduction of callus can prevent ulceration.
During the acute stage, charcot foots foot may be misdiagnosed as;
Cellulitis
Osteomyelitis
Deep vein thrombosis
Inflammatory arthropathy
Therefore a high index of suspicion is very important at this stage!

Management

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Amputation

How you should


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...if the foot does not stabilise or ulcer is


worsening?- Definitive management

Learning outcomes

Amputation

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Referral to vascular surgeons for possible


amputation is made on clinical findings that the
ulceration is not healing/ infection worsening in spite
of intensive antibiotic therapy
Signs include:
Extensive tissue loss
Unreconstructable ischaemia
Failed revascularisation
Charcots of ankle with instability

Pain

Management

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What about giving them some analgesia?

Treating painful diabetic neuropathy:


General approach;
Reassure the patient that intense pain improves within 2 years.
Regular appointments to monitor their pain and try new strategies if refractory to
previous attempts.
It is essential to optimise diabetic control.

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Drugs;

Section two quiz

Simple analgesics; e.g. aspirin, paracetamol, and mild opiates such as codeine
phosphate singly or in combination. Prescribe hypnotics for disturbed sleep.

Management
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Trycyclic antidepressants; e.g imipramine, amitriptyline. Commence with low dose


and gradually increase according to symptomatic response
Anticonvulsants; e.g carbamazepine, valproate, phenytoin, gabapentin,
lamotrigine may be very useful. The latter two may improve sleep in addition to pain
relief.
Capsaicin is a very useful topical analgesic

Management

New Surgical Techniques

Title slide

So thats where we are at the moment. How about future


developments?

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Prophylactic foot surgery:

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The last decade has a dramatic interest in reconstructive foot surgery for
the diabetic foot. The aim of this surgery is to reduce risk of ulceration.
A short Achilles tendon may be associated with elevated forefoot plantar
pressure and hence may benefit from Achilles tendon lengthening
surgery.
Tenotomy of toe extensors may reduce toe deformities, thus preventing
recurrent ulcerations in this group of patients.
Metatarsal osteotomy may reduce the risk of ulcer recurrences in
subjects with prominent metatarsal heads.
However, currently there is no randomise control trial evidence comparing
these surgical techniques with medical therapy.

End of Section 3
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Well done!
You have come to the end of the last section

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We suggest that you answer Question 10 to 18


to assess what you have learnt. Please
remember to write your answers on the mark
sheet before looking at the correct answers!

Section 3 Quiz
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Question 10: Write T or F on the answer sheet. First complete all 5


questions, then click on the boxes and mark your answers.
Good shoe guide:
a)
Toe box should be sufficiently long, broad and deep to
accommodate the toes without pressing on them, with a clear
space between the apices of the toe box
b)

Shoes should be fasten with adjustable lace, strap or


velcro high on the foot in order to hold foot firmly inside
the shoe and thus reduce frictional forces when the patient
walks

c)

The heel of the shoe should be over 5 cm high


to avoid weight being thrown forward into metatarsal heads

d)

The inner lining of shoe should be smooth

e)

Stocking or socks should not be worn with shoes

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Section 3 Quiz
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Question 11: List five common foot problems that occur


in the population at large.Write your answer in your
mark sheet

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1)
2)
3)
4)
5)

.
.
.
.
.

Click here for the


answers

Section 3 Quiz
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Question 12: Identify the following photos below. Write your


answer in your mark sheet.

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the answers

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Section 3 Quiz
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Question 13: name three cast techniques used for offloading pressure in neuropathic diabetic foot. Write your
answer in your mark sheet

1) .
2) .
3) .

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answers

Section 3 Quiz
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Question 14: List five reasons why debridement is


important in the treatment of diabetic foot ulcers. Write
your answer in your mark sheet

1)
2)
3)
4)
5)

..
..
..
..
..

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answers

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Question 15: List 4 oral and 4 parenteral antibiotics used in


treating infected diabetic foot ulcers.Write your answer in your
mark sheet

Oral antibiotics;
1)
..
2)
..
3)
..
4)
..
Parenteral antibiotics;
1)

2)

3)

4)

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answers

Section 3 Quiz
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Question 16: Describe the term charcot foot and


mention its three phases of evolution .Write your
answer in your mark sheet

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a)
b)
c)

.
.
.

Click here for the


answers

Section 3 Quiz
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Question 17: identify the following photos below.


Write your answer in your mark sheet

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Section 3 Quiz
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Question 18: List 5 categories of drugs used in the


treatment of painful diabetic neuropathy. Write your
answer in your mark sheet.

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A.
B.
C.
D.
E.

Click here for the


answers

Sources of Information/Images and References


1.
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Pathophysiology

2.
3.
4.
5.

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6.
7.
8.

A Clarke (2005). Pathology of the non-ulcerative foot. Diabetes


voice; volume 50.
http://www.emedicinehealth.com/diabetic_foot_care
Time to Act (2005). International Diabetes Federation and the
International Working Group on Diabetic Foot.
Edmonds ME, Foster AVM (2005). Managing the diabetic foot (2nd
edition). Blackwell Science, Oxford.
Khanolkar MP, Stephens JW, Bain SC. (2007) The Diabetic Foot.
(in press). Morriston Hospital, Swansea, UK.
www.zoobiotic.com; LarvE data card version 2.9 and dressing
application version 2.0 (2007).
Levin and ONeal. Eds. John H. Bowker and Michael A. Pfeifer.
(2007) The Diabetic Foot. Mosby, Elsevier. 7th edition
The 5th International Symposium on the Diabetic Foot. (May 9-12,
2007). International Diabetes Federation. Noordwijkerhout, the
Netherlands,.