Post on 22-Jan-2015
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DiabeticDiabetic FootFoot(siti zarina)(siti zarina) 1
Why you should wake up and focus on this presentation?
2006 Third National Health Morbidity Surveya) prevalence rate of diabetes mellitus has been
reported to have increased from 8.3% in 1996 to 14.9% in 20061
b) prevalence of lower limb amputation among patients with diabetes was 4.3%.
c) Our MBBS exam
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HISTORY
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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?
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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?
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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
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Physical examination
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a) General : any sign of inflammationb) Local examination : compare both limbs.
Check the normal one first
Musculoskeletal status
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Attitude and postureAttitude and posture
Orthopaedic deformitiesOrthopaedic deformities
Limited joint mobility, muscle strength
Limited joint mobility, muscle strength
Tendo-Archilles contractures/equinus/foot drop
Tendo-Archilles contractures/equinus/foot drop
Gait evaluationGait evaluation
Plantar pressure measurementPlantar pressure measurement
Skin and nails of footSkin and nails of foot
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Skin appearance: color, texture, turgor, quality and dry skin
Calluses, heel fissures, cracking of skin
Nail appearancesPresence of hair
Ulceration, gangrene, infection
Interdigital lesions, tinea pedis
Vascular status of foot
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Pulses Pulses
Capillary refill timeCapillary refill time Edema Edema
Color change Color change
Temperature gradientTemperature gradient
Venous filling timeVenous filling time
Changes of ischemiaChanges of ischemia
Neurological status of foot
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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
Evaluation of foot wear
• Type and condition of shoes and sandals• Fit• Shoe wear, pattern of wear, lining wear• Foreign bodies• Insoles, orthoses
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Investigation
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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
Diabetic foot ulcer
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Neuropathy
Peripheral vascular disease
Abnormal foot pressure
Hyperglycemia
Trauma
Foot deformity Limited joint mobility
Previous ulceration and amputation
Poor vision
Chronic renal disease
Old ageCondition 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
Pathogenesis
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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
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Wagner’s foot ulcer classification
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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
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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: a) mechanical (surgical debridement, high pressure irrigation,
wet to dry dressing),b) Enzymaticc) Autolytic
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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
Off-loading
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• 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
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Treatment of infection
• Early incision and drainage• Empirical broad-spectrum antibiotic.
Vascular management of ischemia
- Vascular supply should be assessed early before surgery intervention
Treat other medical co-morbidities
• DM is a multi-organ systemic disease.• Multi-disciplinary approach.
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
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I & D, debridement, amputation
Empirical regimena) Mild mod infection- gram +ve- 1-2 weeksb) Severe and life threatening-+ve, -ve, enterococci, anaerobic -More than 2 weeksc) If osteomyelitis and have not been amputated: 2-8 weeks
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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
Amputation
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3 D’s
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• Damned Nuisance - dt pain, gross malformation, recurrent sepsis, severe loss of function
• Dead - PVD, trauma, burns, frostbite
• Dangerous - malignant tumours, potentially lethal sepsis, crush injury
Complication
Early • Breakdown of skin flaps• Gas gangrene
Late• Skin- eczema, ulcer• Muscle- improper use
of prosthesis• Artery- ulcer• Nerve- pain & tender• Phantom limb
Patient education
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Patient education
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References • http://www.hrsa.gov/leap/patienteducation.htm
• www.emedicine.com• Boon et al. Davidson’s principle and Practice
of medicine. 20th edition, Churchill Livingstone Elsevier 2006. page;844-846.
• Management of diabetic foot, CPG 2004• http://care.diabetesjournals.org/content/26/1
0/2848.full
• http://www.wagnergradeposter.com/012wagnerpic.jpg
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Thank you =)
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