diabetic foot thongchai pratipanawatr md.. site of diabetic foot ulcers site% toe51 plantar...
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Diabetic foot
Thongchai Pratipanawatr MD.
Site of Diabetic foot ulcers
Site %
Toe 51
Plantar metatatarsal and mid foot
28
Dorsum of foot 14
Multiple ulcers 7
Outcome of Diabetic foot ulcers
Outcome %
Reepithelization/primary healing
63
Amputation 24
Death 13
Diabetic foot ulcer
Neuropathic foot ulcer
Ishemic foot ulcer
Mixed ishemic-neuropathic
Neuropathic foot ulcer
Risk factors of foot ulcers
Diabetic neuropathy increases risk of foot ulcer and amputation.
Neuropathy 1.7-folds
Deformity 12-folds
Previous history of ulcer
36-fold
Distal sensory neuropathy
Loss pain, temperature And fine touch sensation burning sensation
Vibration, Position sense, Touch/pressure
Motor: intrinsic muscle
Small fiber
Large fiber
Distal sensory neuropathy
Diagnosis10 gm monofilament: small fiber128 Hz tuning fork: large fiberMotor deformity: large fiber
Sensory neuropathy
Loss of protective sensation5.07 (10 gram) Monofilament
Area of examination
Deformity
Abnormal Foot pressure
Deformity
Claw toesClaw toes
Neuropathic foot ulcer
Loss of sensationDeformityCallous formationCallous ruptureFoot ulcerInfection
Diabetic foot ulcer
Insensitive footInappropriate shoe (too tight)DeformityIschemic foot ulcer
Insensitive foot
Insensitive foot
Insensitive foot examination
Examination Justification
General Inspect for possible ulceration
Sensory Test sensation
Temperature Local temp increase more than 2 C indicates of infection
Shoes Inspect foot ware
Muscle Muscle deformaty
Neuropathic foot ulcer
Loss of sensationDeformityCallous formationCallous ruptureFoot ulcerInfection
Claw toes
DeformityDeformity
Hammer toes
DeformityDeformity
21
CallousCallous
22
UlcerUlcer
Chronic ulcer with osteomyelitis
OsteolyticOsteolyticbonebone
Charcot’s foot
Charcot’s foot
Acute Charcot’s foot
Chronic Charcot’s foot
Charcot’s foot
Chacort’s deformity
Others neuropathic ulcer
Too tight shoe
Too tight shoe
Too tight shoe
Too tight shoe
Too tight shoe
Too tight shoe
Ishemic foot ulcer
Ischemic foot ulcer
Ischemic foot ulcer
Ischemic foot ulcer
Diabetic foot care
Risk factors of foot ulcers
Diabetic neuropathy increases risk of foot ulcer and amputation.
Neuropathy 1.7-folds
Deformity 12-folds
Previous history of ulcer
36-fold
Management category
Risk Sensation Deformity Hx of ulcer
0 Present No No
1 absent No No
2 absent Yes No
3 absent Yes Yes
Management category
Risk Managment
0 Foot clinic one a year; foot education
1 Foot clinic every 6 months, appropriated footwear and soft insole
2 Foot clinic every 3 months, custom-molded orthotic devices
3 Foot clinic every 1-2 months, custom-molded orthotic devices
Foot education
Daily cleaning
Skin & nail care
46
ผิ�วแห้�งผิ�วแห้�ง-- แตกแตก
Appropriated footwear and soft insole
Proper shoes design
Proper shoes &soft insole
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รองเท้�าท้��ไม�เห้มาะสมก�บเท้�า รองเท้�าท้��ไม�เห้มาะสมก�บเท้�า
Custom-molded orthotic devices
Soft inserts
Mold insoles
Total contact insole
Foot wear
57
CallousCallous
58
CallousCallous
Diabetic wound care
Depth-ischemia classification
Grade Definition
0 At risk (previous ulcer or neuropathy with deformity
1 Superficial ulcer, no infection
2 Deep ulceration exposing tendon or joint (with or without infection)
3 Extensive ulceration with expose bone or deep infections
Depth classification
Depth-ischemia classification
Depth-ischemia classification
Grade Definition
A Not ischemia
B Ischemia without gangrene
C Partial (forefoot) gangrene of the foot
D Complete foot gangrene
Ischemia classification
Depth-ischemia classification
Depth-ischemia classification
Grade Definition
0 At risk (previous ulcer or neuropathy with deformity
1 Superficial ulcer, no infection
2 Deep ulceration exposing tendon or joint (with or without infection)
3 Extensive ulceration with expose bone or deep infections
Depth classification
Depth-ischemia classification
Grade Intervension
0 Patient education and appropriated foot ware
1 External pressure relief
2 And surgical debridement (antibiotic)
3 And antibiotic; amputaiton may be
Depth classification
Off-loading
Total contact cast (TCC) -gold standardPrefabricated pneumatic walking brace ( Air
cast )Half-shoesCrutches,Walkers and WheelchairsBed rest
Total contact cast
Air cast
Half shoe
Modified/custom shoes/orthoses
Surgical intervenion
DebridementAmputationOsteotomyBone stabilizationTendon tranfer or Tenotomy Achilles tendon lengthening tendonetc.
Depth-ischemia classification
Grade Definition
A Not ischemia
B Ischemia without gangrene
C Partial (forefoot) gangrene of the foot
D Complete foot gangrene
Ischemia classification
Vascular screening♦ Hair loss♦ Color♦ Baked potato skin♦ Capillary filling time♦ Temperature♦ Pulses♦ Ankle brachial index (ABI)
Thank you