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The severity of diabetic foot disease is not related to the severity of the diabetes but rather to the adequacy of blood sugar control. Pathology • One-third of diabetic foot ulcerations are neuropathic • One-third are ischaemic • One-third are mixed in nature Neuropathy Symmetrical distal polyneuropathy involving motor, sensory and autonomic nerves. Investigations For nerve function • Biothesiometer. Measures vibration perception threshold. The calculated standard deviation score evaluates the risk of ulceration • Semmes–Weinstein hairs: nylon monofilaments of the same length but different diameters. If the 5.07 hair can be felt, the patient has protective sensation • Nerve conduction studies. Can give spurious results if some fibres are conducting and others
ESR • Plain radiographs looking for osteomyelitis • Bone scan or labelled white cell scan Management • Eliminate infection • Remove infected bone • Drain abscesses Neuropathic ulcers These are healed by limitation of causative . Normal value is 1 and a value <1 indicates peripheral vascular disease. Give antibiotics only if there is clinical evidence of cellulitis. Streptococci and anaerobes. There is usually a polymicrobial colonization of foot ulcers. Treat with caution in diabetics as calcification of the arteries makes them relatively incompressible and gives spurious results • Angiography For infection • Culture and stain. Most common organisms are Staphylococcus aureus. Escherichia coli.are not For vascular status • Doppler ultrasound • Ankle/brachial index. abscess or evidence of osteomyelitis • White cell count.
and a hole cut where the ulcer is. Surgery • Debridement of infected ulcers. a rocker for walking. if it does. If it does not bleed. neuropathic.mechanical forces. Aim for prevention of further ulceration through good diabetic control and well fitting shoes. Strict bed rest is expensive and has a risk of complications. Arteriography is helpful to determine whether angioplasty or bypass surgery is possible. Advise non-weightbearing on crutches and a total contact plaster padding. Apply a below-knee plaster cast with minimal Oral questions • Discuss the role of amputation in the diabetic foot • Describe how to salvage “the foot at risk” . Ulcers of mixed aetiology Usually there are more ulcers of one type than of the other. it is likely to be ischaemic. Ischaemic ulcers These are made worse by total contact plasters. drainage of abscesses and excision of infected bone • Revascularization of ischaemic foot • Amputation for gangrenecast.