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Managing the Diabetic Foot
Hemi SinoritaSub Department of Endocrinology and Metabolism
Department of Internal MedicineMedical Faculty, Gadjah Mada UniversityDr. Sardjito Hospital, Yogyakarta
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INTRODUCTION
Foot disorders are a major source ofmorbidityLeading cause of hospitalization
The prevalence of foot ulcerspopulations 2% - 10%
7-20% : amputation> 80% are potentially preventable
THE JOURNAL OF FOOT & ANKLE SURGERY, 2006.
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Frygberg et al , 2006
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ASSESSMENT OF THE FOOT
1. Neuropathy2. Ischaemia
3. Deformity4. Callus5. Swelling6. Skin breakdown7. Infection8. Necrosis
Wound Essentials Volume 2 2007. Edmons &Foster, 2009
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1. NeuropathySensory loss is recognised asa major
cause of diabetic foot ulceration.45 60% of all diabetic ulcerations are due
to peripheral neuropathy
The presentation of peripheralneuropathy is related to dysfunction ofsensory, motor and autonomic nerve
Frykberg et al, 2006 Edmons & Foster, 2009
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Motor neuropathy
The classical sign of amotor neuropathy :a high mediallongitudinal arch
prominent metatarsal
pressure point of plantar
forefoot
http://www.thefootandankleclinic.com/images/uploaded/footother01.jpg
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Autonomic neuropathy
The classical sign of autonomic neuropathy are :Dry skin with fissuring
Distended veins over the dorsum of the footand ankle
Liau, 2009; http://upload.wikimedia.org/wikipedia/commons/thumb/1/17/DFS_bei_AVK.jpg/300px-DFS_bei_AVK.jpg
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Sensory neuropathy
Can be simply detected by :MonofilamentsNeurothesiometry
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2. IschaemiaResults from atherosclerosis of the arteries of the legUlceration or necrosis is the commonest
presentation of ischaemia The skin is thin, shiny, and wihout hair. There is atrophy of subcutaneus tissue.
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ABINormal 0.91-1.30Mild obstruction 0.71-0.90*Moderate obstruction 0.41-0.70*Severe obstruction 0.40**Poorly compressible >1.30
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Callus
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Corn
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Swelling, Skin breakdown, Infection, Necrosis
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A. Identifying risk status
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Basic foot examination
1. History of previous ulceration or amputation2. Identifying whether there is a visual or physical difficulty
that prevents appropriate self-care3. Palpation of foot pulses dorsalis pedis and posterior tibial
pulses, capillary refill testing and ankle:brachial pressureindices (ABPI) if pulses are diminished
4. Testing for sensory loss with a 10gram monofilament or a128Hz tuning fork
5. Inspection of the feet for deformities (hammer toes,clawed toes or bony prominences), toenaildeformities/pathology and skin pathologies such as callusand corn .
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Risk 1
Low riskNo increased risk of foot problemsNo signs of peripheral neuropathyNo peripheral vascular diseaseNo foot deformity
Annual review
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Inspect feet at every office visitPodiatry care stratified to risk level
Intensive patient educationDetect/manage barriers to foot care
Therapeutic footwear, if needed
2006. American College of Physicians. All Rights Reserved.
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Patient and family educationassumesa primary role in prevention.Such education encompassesinstruction in
glucose assessmentinsulin administrationdietdaily foot inspection &
care proper footwear prompt treatment of newlesions t
THE JOURNAL OF FOOT & ANKLE SURGERY,2006
BASIC FOOT CARE CONCEPTS
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Daily foot inspection & care proper footwear
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BASIC FOOT CARE CONCEPTS
Protective behaviors: Avoid temperature extremesNo walking barefoot/stocking-footed
Appropriate exercise if sensoryneuropathyBicycle/swim >
walking/treadmill
Inspect shoes for foreignobjectsOptimal footwear at all times
2006. American College of Physicians. All Rights Reserved.
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BASIC FOOTWEAR EDUCATION
Avoid:Pointed-toesSlip-onsOpen-toesHigh heelsPlasticBlack color
Too small
Diabetes Self-Management 2005; 22:33
2006. American College of Physicians. All Rights Reserved.
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BASIC FOOTWEAR EDUCATION
Favor:Broad-round toes
Adjustable (laces, buckles,
Velcro) Athletic shoes, walking shoesLeather, canvas
White/light colors between longest toe and
end of shoe
Diabetes Self-Management 2005; 22:33
2006. American College of Physicians. All Rights Reserved.
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Risk 2 Medium risk
Peripheral vascular disease and/or peripheralneuropathyImpaired sensationFoot deformities
Every 3 to 6 months
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BASIC FOOT CARE CONCEPTS
Commitment to self-care:
1. Wash/dry daily Avoid hot water; dry
thoroughly between toes
2. Lubricate daily (notbetween toes)3. Debride callus/corn
avoid sharp instruments- corn plasters
4. No self-cutting of nailsif: Neuropathy, PAD,
poor vision 2006. American College of Physicians. All Rights Reserved.
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Risk 3High risk
Peripheral neuropathyPeripheral vascular disease
History of previous footulcers or amputation
Every 1 to 6 months
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Risk 4
Acute foot problems Acute foot problems, e.g. ulcerationIschaemiaInfection
Acute Charcot foot
Every 1 to 7 daysdependent on need
International Concensus on the Diabetic Foot, 1999; Frykberg et al, 2006
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B. Managing diabetic foot ulcers
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Primary Goals of Treatment
1. Prevent limb loss
2. Prevention of ulceration and recurrence3. Early recognition and treatment ofdiabetic foot complications
4. Maintain quality of life
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Prevent limb loss
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Managing diabetic foot ulcers
1. Advocate tight glycaemic control 2. Identify aetiological factors Identify factors that have directly causedthe ulcer : ill-fitting footwear .Factors that have contributed to theulceration and can contributeto a delay in healing :
peripheral neuropathy peripheral arterial disease .
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Managing diabetic foot ulcers
3. Establish and quantify vascular status4. Manage arterial risk factors
BP < 130/80mmHg (drugs and lifestylemodification : salt, alcohol, weight loss,increased activity); Dyslipidaemia;
Stop smoking
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Managing diabetic foot ulcers
5 Rapid management of infection
Foot infections are common>50% not show classic signs ofinfection due to a poor bloodsupply that reduces
inflammation, redness and heat,and neuropath y that will mask pain. An increase in exudate volume-malodour
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t
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t
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Managing diabetic foot ulcers
6. Identify wound
characteristics Tissue removal isparamount for effective
wound bed preparation.Inflammation or infection :prompt recognition andmanagement of infection is
vital for healing.Moisture imbalance: toprevent the wound bedbecoming too dry or toomoistEpithelium advancing
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Managing diabetic foot ulcers
7. Establish and quantify neurologicalcomplications and pain45 60% of all diabetic ulcerations are purelyneuropathic, approximately 45% are
neuroischaemic
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Managing diabetic foot ulcers
8. Employ offloading strategiesPressure reduction is a key aspect at preventingand healing. Therapeutic footwear hasalso been shown to have a beneficial
role in the primary
and secondary prevention of diabetic foot ulcers
http://www.emedicine.com/orthoped/images/1230552-1234396-374.jpghttp://www.emedicine.com/orthoped/images/1230552-1234396-374.jpg8/14/2019 Diabetic Foot 12 Des
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t t
THE JOURNAL OF FOOT & ANKLE SURGERY,2006
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terima kasih
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DepthClassification Definition Treatment
0 At-risk foot, no
ulceration
Patient education,accommodative footwear,regular clinicalexamination
1
Superficialulceration, notinfected
Offloading with total contactcast (TCC), walking brace,or special footwear
2
Deep ulcerationexposing tendons
or joints
Surgical debridement, woundcare, offloading, culture-
specific antibiotics
3Extensive ulceration
or abscess
Debridement or partialamputation, offloading,culture-specific antibiotics