Diabetic Foot An Overview

Foot team• Prof.Mamdouh El Nahas

• Prof.Hanan Gawish

• Dr. Manal Tarshoby

• Dr.Omnia State

Put Feet FirstPrevent Amputations

Diabetes and Foot Care

World Diabetes Day 2005

2005: a Year-long Campaign

Campaign Objectives

• Inform people of the extent of diabetic foot problems worldwide.

• Persuade people that action is both possible and affordable.

• Warn people of the consequences of not taking action.

FOOT FACTS (1)

• Every 30 seconds a leg is lost to diabetes somewhere in the world.

• Up to 70% of all leg amputations happen to people with diabetes.

• DF problems are the commonest cause of hospital admission. (by us?)

FOOT FACTS (2)

• Most amputations begin with a foot ulcer.

• One in every six people with diabetes will have a foot ulcer during their lifetime.

• Good News Up to 85% of amputations can be avoided.

Egypt Representative

Mansoura University

Prof.Mamdouh El Nahas.

Dr.Hanan Gawish

Dr. Manal Tarshoby

Dr.Omnia Stat

Levels of foot management

• Level 1 General practitioner, diabetic

nurse and podiatrist

• Level 2 Diabetologist, surgeon (general

and/or vascular and/or orthopedic),

diabetic nurse and podiatrist

• Level 3 Specialized foot center

Value of Podiatric Care

0

2

4

6

8

10

12

14

84 85 86 87

Year

% A

mp

uta

tio

ns •KINGS COLLEGE HOSPITAL.

•1984 establishment of DIABETIC FOOT CLINIC.

•Amputation decreased 50% in 3 years.

Diabetic Foot

Diabetic Foot Disease

• Ischaemia• Neuropathy• Infection• Structural deformity • Ulcer• Amputation

Five cornerstones of the management of the diabetic foot

Regular inspection and examination of the foot.Identification of the foot at risk.Education of patient, family and healthcare providers.Appropriate footwear.Treatment of non ulcerative pathology

Five cornerstones of the management of the diabetic foot

Regular inspection and examination of the foot.Identification of the foot at risk.Education of patient, family and healthcare providers.Appropriate footwear.Treatment of non ulcerative pathology

Regular inspection and examination of the foot

• All diabetic patients should be examined at first presentation then at least once a year

• Patients with risk factors should be examined every 1-6 months

• Absent symptoms does not mean that the feet are healthy

• Examine the patient on lying down and standing up

• Shoe and socks should be inspected

History

• Previous ulcer , amputation• Previous foot education• Bare-foot walking• Poor access to healthcare• Smokimg , alcohol• Nephropathy,Retinopathy• Hypertension• Ischemic heart disease

Foot examination

1. Nails Thick

too long

ingrown

fungal infection

wrongly cut nails

Foot Examination

2.Foot deformity:

Foot Examination

2.Foot deformity: Toe deformity

• Hammer toeHammer toe• Claw toeClaw toe

Toe Deformity:– Hammer Toe

• Increased pressure on 2ndmetatarsal head• Increased pressure on prox. IPJ• Increased pressure on distal IPJ• Increased pressure on apex• Increased pressure on nail fold

Foot Examination

2.Foot deformity: Toe deformity

Forefoot deformity• Hallux valgusHallux valgus

• Hallux rigidusHallux rigidus

Hallux Valgus

Hallux Rigidus

Osteoarthritic Degeneration 1st MTP Joint

Limitation of Dorsiflexion

Overloading 2nd MTP Joint / 1st IPJoint

Foot Examination

2. Foot deformity: Toe deformity

Forefoot deformity

Wholefoot DeformitiesWholefoot Deformities

• Pes Cavus - High arched footPes Cavus - High arched foot• Pes Planus - Flat footPes Planus - Flat foot• Charcot footCharcot foot

Diagnosis of Acute Charcot Painless

Redness, swelling, and more than 2°C skin temperature difference when compared with the contralateral foot.

Dorsalis pedis pulses are often bounding.

The patient is afebrile unless a systemic infection is present.

Foot Examination

2.Foot deformity: Toe deformity

Forefoot deformity

Whole foot DeformitiesWhole foot Deformities

Prominent metatarsal headsProminent metatarsal heads

Foot Examination

3.Skin condition:

Callus BunionsCallus Bunions Redness WarmthRedness Warmth Fissure DrynessFissure Dryness Swelling MacerationSwelling Maceration Fungal infectionFungal infection

Callus

• Presence of callus is a significant marker for the development of foot ulceration

• The hyperkeratosis is a result of hypertrophy under the influence of intermittent compression .

• the callus is either a reaction to abnormal pressure or an abnormality of the area to handle normal pressure.

Tenia Pedis

Foot Examination

4.Vascular assessment:

History Intermitent claudicationIntermitent claudication

Rest painRest pain

Colour of the skin

Temperature gradient

Foot Examination

4.Vascular assessment:

Pedal pulse Dorsalis pedisDorsalis pedis

Posterior tibialPosterior tibial

Foot Examination

4.Vascular assessment:

Pedal pulse Dorsalis pedisDorsalis pedis

Posterior tibialPosterior tibial

Ankle Brachial Pressure Index

Foot Examination

5. Neurological assessment:

Neurologic assessmentNeurologic assessment

Temperature Temperature Vibration Sense Vibration Sense Pressure Sense Pressure Sense Light Touch Light Touch Proprioception Proprioception ReflexesReflexes

Neurologic assessmentNeurologic assessment

Neurologic assessmentNeurologic assessment

Temperature Temperature Vibration Sense Vibration Sense Pressure Pressure SenseSense Light Touch Light Touch Proprioception (Romberg’s Sign)Proprioception (Romberg’s Sign) Superficial Pain Superficial Pain ReflexesReflexes

TEMPERATURE TESTINGTEMPERATURE TESTING

Two test tubes, hot/cold.Two test tubes, hot/cold. Therm-tipTherm-tip Subjective, crude testsSubjective, crude tests

Neurologic assessmentNeurologic assessment

Temperature Temperature Vibration Sense Vibration Sense Pressure Pressure Sense Sense Light Touch Light Touch ProprioceptionProprioception Superficial Pain Superficial Pain ReflexesReflexes

VIBRATION SENSEVIBRATION SENSE

NEUROTHESIOMETERNEUROTHESIOMETER

Neurologic assessmentNeurologic assessment

Temperature Temperature Vibration SenseVibration Sense Pressure Pressure Sense Sense Light Touch Light Touch Proprioception Proprioception Superficial Pain Superficial Pain ReflexesReflexes

MONOFILAMENTSMONOFILAMENTS

10 gm Sites tested Technique Significance

Neurologic assessmentNeurologic assessment

Temeprature Temeprature Vibration Sense Vibration Sense PressurePressure Sense Sense Light Touch Light Touch ProprioceptionProprioception Superficial Pain Superficial Pain ReflexesReflexes

LIGHT TOUCH TESTLIGHT TOUCH TEST

Neurologic assessmentNeurologic assessment

Temperature Temperature Vibration Sense Vibration Sense Pressure Pressure Sense Sense Light Touch Light Touch ProprioceptionProprioception Superficial Pain Superficial Pain ReflexesReflexes

PROPRIOCEPTION TESTPROPRIOCEPTION TEST

Tested by dorsiflexing Tested by dorsiflexing and plantarflexing the and plantarflexing the hallux. Can the patient hallux. Can the patient determine the position determine the position

of the hallux?of the hallux?

Neurologic assessmentNeurologic assessment

Temperature Temperature Vibration Sense Vibration Sense Pressure Pressure Sense Sense Light Touch Light Touch Proprioception Proprioception Superficial Pain Superficial Pain ReflexesReflexes

SUPERFICIAL PAIN TESTSUPERFICIAL PAIN TEST

Neurologic assessmentNeurologic assessment

Temperature Temperature Vibration Sense Vibration Sense Pressure Pressure Sense Sense Light Touch Light Touch ProprioceptionProprioception Superficial Pain Superficial Pain ReflexesReflexes

ANKLE REFLEXANKLE REFLEX

Five cornerstones of the management of the diabetic foot

Regular inspection and examination of the foot.Identification of the foot at risk.Education of patient, family and healthcare providers.Appropriate footwear.Treatment of non ulcerative pathology

Risk Categorization

Risk categorization system

  Category Risk profile Check-

up frequency

0 no sensory neuropathy once a year

1 sensory neuropathy once every 6

months

2 sensory neuropathy and signs of peripheral vascular disease and/or foot deformities.

once every 3 months

3 previous ulcer once every

month

Five cornerstones of the management of the diabetic foot

Regular inspection and examination of the foot.Identification of the foot at risk.Education of patient, family and healthcare providers.Appropriate footwear.Treatment of non ulcerative pathology

Five cornerstones of the management of the diabetic foot

Regular inspection and examination of the foot.Identification of the foot at risk.Education of patient, family and healthcare providers.Appropriate footwear.Treatment of non ulcerative pathology

Five cornerstones of the management of the diabetic foot

Regular inspection and examination of the foot.Identification of the foot at risk.Education of patient, family and healthcare providers.Appropriate footwear.Treatment of non ulcerative pathology

What is going on??

Foot care team

• ??Podiatrists

• Orthotists.

• Diabetologists.

• Vascular Surgeon.

• Educators.

• Microbiologist.

Ulcer assessment

1.Establish the ulcer's etiology2.Measure its size3.Establish its depth and involvement of deep

structures4.Examine it for purulent exudates, necrosis,

sinus tracts, and odor5.Assess the surrounding tissue for signs of

edema, cellulitis, abscess, and fluctuation6.Exclude systemic infection7.Perform a vascular evaluation. 8.The ability to gently probe through the ulcer to

bone has been shown to be highly predictive of osteomyelitis.

(should be recorded at base line and every subsequent visits ± digital photo)

• A multidisciplinary approach

providing debridement, meticulous wound care, adequate vascular supply, metabolic control, antimicrobial treatment and relief of pressure (offloading) is essential in the treatment of foot ulcer.

Dressing

Do not put anything on the ulcer that you wouldn’t put in your eye!!

No evidence from large trials

Debridement

Sharp LarvalEnzymatic (Lytic)

Indication & Contraindication??

Offloading

Offlaoding

• What is meant by offloading

• Different offloading modalities

Key Message• Of all late complications of diabetes, foot problems

are the most easily detectable and easily preventable.

• Relatively simple interventions can reduce

amputations by 50 - 80%. (Bakker et al 1994).

• Strategies aimed at preventing foot ulcers are cost effective and cost saving.

• Only champions willing to act are needed.

Don’t Forget to take your copy!

Thanks for sharing!!!!Thanks for sharing!!!!