Dr. Sushil Vijay PG Student, D.

Orth Santosh Medical college & Hospital

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Why this topic is important??

 We

all want a fully functional, normal healthy pair of legs.

Also..

The top 10 countries with Diabetes 2003 -2025

From Internations Diabetic Federation

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Risk Level 3: Prior amputation Prior ulcer 2: Insensate and foot deformity or absent pedal pulses 1: Insensate 0: All normal

Foot Ulcer %/yr

28.1% 18.6%

6.3%

4.8% 1.7%
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 Understand

pathogenesis of diabetic foot

ulcers
Effectively

evaluate a diabetic ulcer for a treatment plan for diabetic

infection
Formulate

ulcers
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Because!

It is haemodynamically poorly placed.

It is exposed to trauma by frequent contact with the ground. It is that part of the body farthest away from the CNS*
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1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14.

Definition Epidemiology Fate of diabetes Pathophysiology Etiopathogenesis Clinical features Stage of ulcer development Classification/grading of ulcer Evaluation of a patient Management Neuropathic joint- Charcot joint Patient Education Prevention/Treatment of metatarsal head ulcer Diabetic foot care for other ailments.

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Definition:-

Infection, ulceration or destruction of deep tissues associated with neurological abnormalities & various degrees of peripheral vascular diseases in the lower limb
(based on WHO definition)
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 Any

infection (as defined by International Consensus) involving the foot (below the malleoli) in a person with diabetes originating in a chronic or acute injury to the soft tissue envelope of the foot, with evidence of pre-existing neuropathy and ischaemia.

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 Any

foot pathology that results directly from diabetes or its long term complications ( Boulton 2002).

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 DM

is the largest cause of neuropathy. 50% patients dont know that they have diabetes. Foot ulcerations is most common cause of hospital admissions for Diabetics. Expensive to treat, may lead to amputation and need for chronic institutionalized care.

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 Male

Sex DM > 10 years duration Abnormal foot structure Smoking Poor glycemic control

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Repeated Traumatized DFU

Greater & Persistent Inflammatory Response

More Neutrophils & Macrophages Migration

More Cytokine Release

More Inflammatory Cells & Fibroblasts recruited

More TNF-a & IL-1b release

More Macrophage Activation

Increased Release of SerineProteases MMP s TIMPs

Degradation of Matrix proteins, Growth Factors, & Receptors for GF

CHRONICITY OF DFU

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 Diabetic
Diabetic Charcot

foot ulcer
foot infections Joints

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 Combination

of factors

Neuropathy
Ischemic (Peripheral arterial disease) Abnormal foot biomechanics

Delayed wound healing

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NEUROPATHY

THE CRUCIAL TRIAD

REPETITIVE TRAUMA

DEFORMITY

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A.

Neuropathy

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Primary etiology: NEUROPATHY

Sensory Motor

Autonomic

Associated etiology:
Deformity Infection Peripheral Arterial Disease (PAD)

Associated Pathogenic Mechanisms:

Ulceration Decrease in Neurokines including Substance P

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 Truly

multi factorial but one may predominate others. Factors are 1. Neuropathy 2. Macrovascular disease 3. Microvascular disease 4. Connective tissue abnormalities 5. Infections 6. Hematological disturbances
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Glove & stocking type Can be

Sensory / motor/ autonomic Mono / poly radiculopathy

Most commonly neuropathy

distal

symmetric

sensory

Causes: 1]Metabolic factor(Due to hyper glycemia) 2]Microvascular disease Effects: 1]Extrinsic 2]Intrinsic
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 Extrinsic:

Loss of somatic sensations of plantar aspect cause ulcer by: fitting shoe, toe nail, thermal injury, foreign body Pain is not perceived , So damage continues, & Established ulcer is the end point.

ill

Intrinsic:

Causes smooth motor neuropathy Weakness of intrinsic muscles . Abnormal movements of small bones &joint subluxation. Visceral neuropathy cause loss of proprioception . Patient keeps on walking on aching foot (which is not known to him). Stretching of joint capsules & bony changes take place. With continuous shear pressure cause callus & ulcer formation.
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MACROVASCULAR

MICROVASCULAR

Diabetics are 4 to 7 times more prone for atherosclerosis than normal.

Structural abnormalities in: 1]Basement membrane 2]Endothelial function Basement membrane: Leads to defect in movement of leucocytes & macromolecules. Endothelial Function :Defect leads to poor tissue perfusion & play important role in ulceration.
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Mostly affect tibial and peroneal arteries.

Reduced oxygen partial pressure

Vascular calcification seen in xray & angiography.

 Skin

cracks & fungal infection between toes are route of infection. Gram ve & +ve aerobes & anaerobes are noted. Causation of infections increased in diabetes due to:
1.

2.
3.

Deficiency of cell mediated immunity Impaired chemotaxis Impaired phagocytosis & opsonization.

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 Hyperglycemia

affect structure and function of proteins like keratin, collagen. Changes in them and structures become weak & inelastic affect bone structure leading to foot ulcers. `

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 They
1. 2. 3. 4.

cause:

5.

Ischemia Ulceration Spread of infections Red cell deformities ---Hypercoagulability & increased plasma viscocity. All these increase chances of infections.

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Sensory Neuropathy
Loss of Protective Sensation Unrecognized Foot Trauma Ulceration Infection & Impaired Healing

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Motor Neuropathy

Muscle Atrophy

Foot Deformity

Altered Biomechanics

Areas of High Pressure Unrecognized Foot Trauma

Ulceration

Infection & Impaired Healing

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Autonomic Neuropathy
Dry Skin due to Hypohidrosis Altered Cutaneous Blood Supply

Cracks & Fissures

Ulceration

Infection & Impaired Healing

PAD 36

Sensory Neuropathy

Motor Neuropathy

Autonomic Neuropathy

Unrecognized Foot Trauma

PAD

Ulceration

Infection & Impaired Healing

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 B.

DEFORMITY
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 Abnormal

weight bearing Fixed foot deformities

Hammer toe Claw toe

Prominent metatarsal heads

Charcots joints

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Hammer Toes

Claw Toes
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Hallux Valgus

Hallux valgus deformities are more common in persons with diabetes and result in high pressure points from shoe gear at the distal end of the proximal phalanx.

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A marked Hallux valgus deformity and early hammer-toe deformities from diabetic motor neuropathy. Note the areas of persistent erythema over pressure points on the first MTP joint and on the dorsum of the proximal phalanges. This patient requires a modification of shoe gear to relieve pressure and prevent callus and ulcer formation. 42

Severe hammer and claw-toe deformities.

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This patient has a pes cavus or high plantar arch deformity that has resulted in pressure points and callus formation over the heels, metatarsal heads, and along the medial aspect of the great toe. Extensive callus increases the subcutaneous pressure immediately beneath the callus and can result in a subcutaneous hemorrhage, the so-called pre-ulcer.

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 Impaired

wound healing

Does not allow resolution of fissures and

minor injuries Increased chances of infection

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To Summarize all the factors we studied till now

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Causal Pathways for Foot Ulcers

Neuropathy

Deformity

% Causal Pathways Neuropathy: Minor trauma: Deformity: 78% 79% 63%

Minor Trauma
- Mechanical (shoes) - Thermal - Chemical

Behavioral

Poor self-foot care

ULCER
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 Neuropathic

Vascular

disease Small muscle wasting-claw foot Loss of architecture of the foot Pressure points and ulcers

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Shape: change in shape lead to areas

of pressure on prominent metatarsal heads,hammertoes,collapsed mid foot.

Callus: Callus is seen with excessive

wear &tear of tissue.

Skin: Skin is dry and without sweating

due to autonomic neuropathy. Crack easily & a route infection. of

Sensations: Loss of sensations

which are assessed by traditional modalities like ankle jerks, tendon reflex . Pain sensation :reduced & is assessed by biosthesiometer& nylon monofilament.
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NUMEROUS GRADING SYSTEMS

UT: University of Texas SINBAD: Site, Ischemia, infection, Ulcer Area, Depth Neuropathy, Bacterial

S(AD)SAD: Size (Area, Depth), Sepsis, Arthropathy, Denervation

PEDIS: Perfusion, Extent, Depth, Infection, Sensation

Wagner Duss
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GRADE 0 1 2 3 Foot At Risk

DESCRIPTION

INFECTION None None Superficial Infection Deep Infection

Superficial Ulceration Ulcer penetrating to tendon or capsule Ulcer penetrating to bone or joint

ISCHEMIC GRADES:

A = No ischemia; B = Ischemia w/o gangrene; C = partial gangrene; D = complete gangrene

Beckart S, Witte M, Wicke C, et al. Diabetes Care 29: 988-92, 2006

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Palpable Pedal Pulses: Yes = 0, Probing-to-Bone: Site of Location: No. of Ulcers: No = 0, Toe = 0, Single = 0,

No = 1 Yes = 1 Foot = 1 Multiple = 1

Maximum score of 4 possible High score correlate with healing, hospitalization, amputation.

Beckart S, Witte M, Wicke C, et al. Diabetes Care 29: 988-92, 2006

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Site, Ischemia, Neuropathy, Bacterial infection, Ulcer Area, Depth

SITE: ISCHEMIA:

0 = Forefoot

1 = Midfoot, Hindfoot

0 = Pedal Flow Intact; at least one pedal pulse palpable, 1 = Clinical evidence of reduced pedal blood flow

NEUROPATHY: 0 = Protective sensation intact 1 = Protective sensation lost

BA. INFECTION: 0 = None 1 = Present 1 = Ulcer <

ULCER AREA: 0 = Ulcer < 1cm2 1cm2 DEPTH:

0 = Ulcer limited to skin & subcutaneous tissue, 1 = Ulcer reaching muscle, tendon or deeper

Ince P, Abbas ZG, Lutale JK, et al. Diabetes Care 31: 964-67, 2008

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Meggitt-Wagner

ulcer grading

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1. 2. 3. 4. 5.

Skin & Integument Vascular assessment Neurological assessment Musculoskeletal assessment Shoe gear

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VISUAL INSPECTION:

INJURIES & BRUISING DEFORMITIES: Bunions, Achilles contracture, Rocker-bottom foot, Hammertoes VASCULAR SKIN CHANGES: Stasis dermatitis, Skin atrophy, hair loss, nail changes, clear areas of decreased perfusion SHOES FITTING and Presence of Oedema

VASCULAR ASSESSMENT: Palpation of pulses :-Dorsalis Pedis, Post. Tibial A. Temperature of Foot relative to leg, Capillary Refill, Pallor, Ankle-Brachial Index Skin changes Atrophy, Abnormal wrinkling .Absence of hair Onychodystrophy. Venous filling time

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69

NEUROLOGICAL ASSESSMENT: Sensory (pin-prick) assessment vs. contralateral leg and proximal leg Deep Reflexes (Achilles tendon reflex) Vibratory-Proprioception testing (128-Hz tuning fork) Neurological examination Vibration perception Light pressure Light touch Two point discrimination Pain Temperature perception Deep tendon reflexes Clonus Babinski test Romberg test

Semmes-Winstein 10g monofilament (to determine protective sensation)

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DERMATOLOGICAL ASSESSMENT: Skin appearance :-Dryness, Scaling, Swelling, Thickened tissues Calluses Fissures Nail appearance Hair growth Ulceration/infection/ gangrene Interdigital lesions Tinea pedis Capillary Refill, Pallor, Ankle-Brachial Index Deformities

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Musculoskeletal

Biomechanical abnormalities Structural deformities Prior amputation Restricted joint mobility Tendo Achilles contractures Gait evaluation Muscle group strength testing Plantar pressure assessment

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Research has shown that a person who can feel the 10-gram filament in the selected sites is at a reduced risk for developing ulcers. Because sensory deficits appear first in the most distal portions of the foot and progress proximally in a stocking distribution, the toes are the first areas to lose protective sensation.
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 The sensory exam should be done in a quiet and relaxed setting. The patient must not watch while the examiner applies the filament. Test the monofilament on the patients hand so he/she knows what to anticipate.

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 The five sites to be tested

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 Apply the monofilament perpendicular to the skins surface. Apply sufficient force to cause the filament to bend or buckle, using a smooth, not jabbing motion. The total duration of the approach, skin contact, and departure of the filament at each site should be approximately 1 to 2 seconds.
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 Apply the filament along the perimeter and NOT ON an ulcer site, callus, scar or necrotic tissue. Do not allow the filament to slide across the skin or make repetitive contact at the test site.

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Shoe Gear A. Everyday shoe style B. Dress shoe style C. Exercise shoes D. Shoe inserts/orthoses E. Special shoe needs

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INVESTIGATION AND TREATMENT

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1.

Recognition and correction of underlying cause Wound care

Prevention of recurrence

2.
3.

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All diabetic foot ulcers are infected?

All diabetic wounds are colonized?

TRUE

FALSE!

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89

International Working Group on the Diabetic Foot, 2003

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Is osteomyelitis present?
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Diabetic wounds should be swabbed to identify potential pathogens?

FALSE!
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When infected, diabetic wounds are polymicrobial?

FALSE!

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CBC: Hb is specially important Glucose profile: Fasting, PP, HbA1c Inflammatory Markers: ESR, CRP Nutritional Status: Serum Albumin Hepatic & Renal Function Tests Urinalysis Blood C/S Wound C/S X-Ray of both feet, MRI

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If required Arterial Doppler Toe pressure measurement Oxygen tensiometry Arteriogram

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If chr. non-healing ulcer, HUNT for underlying Osteomyelitis

Probe-to-Bone Test Bone Biopsy (gold standard) Appropriate imaging technique:

Plain radiographs of both feet, bone scintigraphy, US, CT, MRI (most-reliable)

Radiographic Milestones:
Radiolucency: 5-7 days Sequestrum & Involucrum: 10-14 days (first signs) Osseous demineralization, periosteal elevation, cortical irregularity usually detected after 35-50% reduction in BMD

Other Radiographic Features:

Soft-tissue edema, Gas in soft-tissues, Foreign Bodies

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Sensitivity Specificity LR+

Plain

films1 scanning1

62% 86% 99% 66%

64% 45% 81% 85% 1.6 5.2 4.4

1.7
Nuclear MRI1

Probing 2
1. 2.

Eckman et al. JAMA 1995;273:712-20 Grayson et al. JAMA 1995;273:721-23

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Estimation of muscle volume of small foot muscles

MRI is gold standard (high spatial resolution permits identification of individual foot ms.) Limitations of MRI:
Cannot be done at bed-side Time-consuming Expensive

Ultrasonography (USG) is good alternative for detecting atrophy Electromyography (EMG)

Severinsen K, Obel A, et al. Diabetes Care 2007; 30(12): 3053-57

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 Plain

X-rays

Osteomyelitis
Fractures Dislocations

Osteolysis
Structural foot abnormalities Arterial calcification

Tissue gas

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10 2

 Non

invasive evaluation

Doppler segmental pressure and

waveform analysis Ankle brachial pressure index Toe blood pressure Transcutaneous CO2 Laser doppler velocimetry

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An ankle-to-brachial pressure ratio of 0.6, an absolute ankle pressure of 70 mm Hg or more, an absolute toe pressure of 40 mm Hg or more, and a transcutaneous oxygen measurement of 30 mm Hg or more are strong indicators that a limited foot amputation should heal, provided that calcification of arteries is thought not to cause falsely high values

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Normal condition on right side of body with ankle systolic pressure equal to brachial systolic pressure. Ankle pressure divided by arm pressure determines ankle/arm index, in this case 1. On left side, ankle/arm index is 0.6, indicating only 60% of expected normal flow at rest. In addition, any gradient greater than 30 mm Hg between two successive cuffs indicates high-grade stenosis or occlusion. In this example, 44 mm Hg high thigh gradient localizes diseased segment to superficial femoral artery
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Interpretation ABI Normal 0.90-1.30 Mild obstruction 0.70-0.89 Moderate obstruction 0.40-0.69 Severe obstruction <0.40 Poorly compressible >1.30 2 to medial calcification
*Poor ulcer healing with ABI < 0.50 **Further vascular evaluation needed
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TREAT Diabetic Foot

PREVENT Diabetes Mellitus

TREAT Diabetes Mellitus

TREAT Other Complications

PREVENTIVE MEASURES Against Diabetic Foot

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 Diet

Control Pharmacological:
Meglitinides

Nateglinide, Repaglinide Side effects of Wt. gain, Hypoglycemia a-Glucosidase Inhibitors More preferred Acarbose Voglibose (better tolerance see next slide)
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Following are used for management of neuropathic pain:

Duloxetine (US-FDA approved) Pregabalin (US-FDA approved)

Others that are used for management of neuropathic pain:

Amitriptyline
Carbamazepine Gabapentin

No option exists for restoration of sensory loss Surgical Nerve Release is controversial and evolving

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Off-Loading: Objective: Pressure normalization on affected areas

Debridement
Wound Care: Objective: to maintain moist wound bed, absorb exudate, prevent infection Antibiotic Treatment: Objective: to treat polymicrobial infection Vascular interventions: Objective: to restore vascular flow Protease Inhibitors: Doxycycline, Gelatin dressing (Promogram) , Metal ions & Citric acid dressing (Dermax) Amputation Growth Factors: rh-PDGF (recombinant human Platelet Derived Growth Factor), VEGF (Vascular Endothelial Growth Factor) Cell Therapy

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Following are some of the OLD:

Bed-rest, wheel chair, Crutch-assisted gait Total Contact Cast (TCC) (Gold standard) Felted Foam Half-shoes Therapeutic Shoes Removable Cast walkers TENDON LENGTHENING***

TCC, though a gold standard, were used by only reported in a survey in 2008. ***Armstrong,JBJS,81:535-8,1999

1.7% centers in USA as

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 Specific

treatment according to the wegners grade of ulcer.

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 For

Wegners grade I just take care of all the basic measures.

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 Wagner

grade 2

Total contact cast

Distributes

pressure and allows patients to continue ambulation Principles of application :- Changes, Padding, removal Antibiotics if infected Surgical if deformity present that will reulcerate
Correct deformity exostectomy
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 Wagner

grade 3

Excision of infected bone

Wound allowed to granulate Grafting (skin or bone) not generally effective

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 Wagner

grade 4-5

Amputation ? level

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Diabetes/Metab Res Rev 2004;20(Supp 1):S68-77

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12 2

 After

ulcer healed

Orthopedic shoes with accommodative

(custom made insert) Education to prevent recurrence

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 Dressings

Gauze pads
Transparent films Hydrogels

Foam
Hydrocolloid Alginate

Collagen dressing
Antimicrobial dressings

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Topical agents

Saline Detergents/antiseptics Povidone iodine Chlorhexidine Hypochlorite Topical antibiotics Bacitracin, neomycin Mupirocin, poly B SSD, mafenide Enzymes Papain urea collagenase
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 Growth

factors

PDGF
VEGF FGF
Autologoud

PRP Bioengineered tissues

Apligraft

Dermagraft

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 Adjunctive

modalities

Hyperbaric oxygen
Ultrasound therapy Vacuum assisted closure

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 Uncontrollable

infection or sepsis Inability to obtain a plantar grade, dry foot that can tolerate weight bearing Non-ambulatory patient Decision not always straightforward

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 Amputation

is indicated to prevent further spread of infection, for uncontrolled infection, osteomyelitis ,and extensive tissue destruction. Also for intractable pain at rest in a limb in which vascular reconstruction has failed or more commonly is impossible due to extensive large blood vessel disease.
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 So

as to avoid reaching at this level for amputation we should follow some precautions

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Prevention
Identification of high risk patients Patient education Careful selection of foot wear Daily inspection of feet Daily foot hygiene
Keep foot clean, moist

Avoidance of self treatment of foot abnormalities and high risk behavior ( walking barefoot) Prompt consultation with health care provider Orthotic shoes and devices Callus management Nail care
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History:
Prior amputation or foot ulcer Peripheral artery disease (PAD)

Exam:

Insensate Foot deformities Absent pulses Prolonged venous filling time Reduced ABI Pre-ulcerative cutaneous pathology
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 CHARCOTS

FOOT

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Defination :- Charcot's joints is a progressive degenerative disease of the joints caused by nerve damage resulting in the loss of ability to feel pain in the joint and instability of the joint. Description Charcot's joints, also called neuropathic joint disease, is the result of two conditions present in the joint. The first factor is the inability to feel pain in the joint due to nerve damage. The second factor is that injuries to the joint go unnoticed leading to instability and making the joint more susceptible to further injury. Repeated small injuries, strains and even fractures can go unnoticed until finally the joint is permanently destroyed. Loss of the protective sensation of pain is what leads to the disintegration of the joint and often leads to deformity in the joint.

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dramatic less common 1% Severe non-infective bony collapse with secondary ulceration Two theories
More

Neurotraumatic

Neurovascular

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 Neurotraumatic

Decreased sensation + repetitive trauma = joint

and bone collapse

Neurovascular

Increased blood flow increased osteoclast

activity osteopenia Bony collapse Glycolization of ligaments brittle and fail Joint collapse

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 Eichenholtz

1 acute inflammatory process Often mistaken for infection 2 coalescing phase 3 reconstructive

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 Location

Forefoot, midfoot (most common) , hindfoot

Atrophic

or hypertrophic

Radiographic finding Little treatment implication

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 Immobilisation Stress

reduction Bisphosphonates Surgery

Exostectomy Arthodesis

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 Int.

J. Leprosy,1971,Yosipovitch et al,39:631-2 Orthopaedics,1996,Lin et al,19(5):465-74 J.B.J.S,1999,Armstrong et al,81A(4):535-8 J. S. Ortho. Assoc.,2003,Laborde,12(2):60-5 J.B.J.S.,2003,Mueller et al,85A(8):1436-45 Surg. Clin. N. Am.,2003,Nishimoto et al,83:70726 Foot & Ankle Int.,2005,Strauss;26(1):5-14 Wounds,2005,Laborde,17(5):122-130
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Met. Head 1-5

Gastroc-Soleus

1st Met. Head

5th Met.Head

Peroneus Longus
Posterior Tibial

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Intramuscular Lengthening(recession) of Gastro-Soleus No Wound Problems No Over-Correction Immediate Full Weight Outpatient

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13. PREVENTION
(PATIENT EDUCATION)

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Patient education is central aim. Daily examination of foot for any ulcer and footwear for foreign body. Creams applied must be allergic & without perfume. Chiropody is advised. Cushions at pressure points must be used. Never walk barefoot. Special types of shoes are adviced. non

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Do

not smoke.

Inspect

toes and between toes daily for blisters, cuts and scratches.

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Diabetic Foot Care Tips

1) Check your feet daily - especially if you have low sensitivity or no feeling in your feet. Sores, cuts and grazes could go unnoticed and you could develop problems leading to amputations. 2) Don't go around barefoot, even indoors. It's easy to tread on something or stub your toes and cut yourself. Protect your feet with socks/stockings and shoes/slippers. 3) Be careful if you have corns or calluses. Check with your doctor or podiatrist the best way to care for them.

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Diabetic Foot Care Tips

4) Wash your feet daily in warm, NOT HOT water. And don't soak your feet (even if you've been standing all day) because it could dry your skin and form cracks or sores. 5) Take extra care to dry your feet completely, especially between your toes. These are natural moisture traps - leaving them damp or wet could create all sorts of problems.

6) Exercise your legs and feet regularly. Even when sitting you can rotate your ankles; wiggle your toes or move your legs up and down. These all keep your blood circulation flowing and helps to minimize the risk of foot problems.
7) Get your feet professionally checked, at least once a year, for sensitivity and signs of any problems. You can usually arrange this when you have your annual check up for your A1C levels (blood glucose levels over a 3-month period), blood pressure and cholesterol.

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Toe

nails should be cut straight across.

Cut

down the sides of the nails can cause in-growing toe nails with its complications
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Inspect your feet each time you take off your socks. Look for small injuries or redness. If you observe such, immediately contact your doctor.

Wash your feet every day with lukewarm water. Do not soak your feet. Measure the temperature of water with a thermometer. Do not exceed 37 C.

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Keep feet clean and dry them well after having a bath, especially between toes. This will prevent you from mycosis.

If your skin is very dry, use neutral creams, if humid, use powder.

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File your nails instead of cutting. Never use sharp instruments for foot care, because they may injure you.

Always check the inner part of your shoes with your hand each time before putting them on. Thus you will avoid injuries due to small objects, which accidentally may have got into your shoes.

Never walk barefoot. Wear soft, comfortable and well fitting shoes. Change daily your socks, stockings or tights

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Never use cutting instruments and chemicals (astringent lotions and corn cures) for foot care. Do not use hot water bottles and electric devices to warm up your feet, because you may not feel well enough the temperature, due to loss of pain sensation.

If you have an injury, immediately call your doctor.

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better shoe is the soft-topped lace up shoe with plenty of room in toe box.

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1.

2. 3. 4.

Use of lubricants for dry skin, do not put between toes to avoid infection and laceration. Avoid extremes of temperature. Test water before bathing. If feet feel cold at night, wear socks, do not apply hot water bottles or heating pads. Do not use chemical agents for removal of corns and calluses.

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Inspect inside of shoes daily for foreign objects, nail points and linings.

Wear properly fitted stocking, do not wear mended stocking. Avoid stocking with seams and change them daily.
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5. 6.

7.
8.

Do not wear garters. Make certain that shoes are comfortable at time of purchase. Do not depend on them to stretch out. Wear shoes made of leather, not manmade materials. Tie shoes laces over top of shoes, not crisscross over tongue of shoes. This avoids pressure on top of the foot.

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10. 11. 12.

Do not wear shoes without stocking. Do not wear sandals with thongs between toes. Do not walk bare footed specially on hot surfaces such as sandy beaches or around swimming pools.

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Do not cut corns and calluses. See your physician regularly. If your vision is impaired, have a family member inspect your feet daily, trim nails and buff down calluses. Be sure to inform your podiatrist that your are diabetic.

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1.

Eliminate weight bearing by:

Bed rest. Special walking cast.
1. Total Contact Casts

2. Pneumatic Walkers 3. Slipper casts

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 Provide

good pressure relief for ulcers &stability for Charcot joint. Effective for non compliant patients. Not suitable for elderly patients &cannot be used for longer than 3 weeks. Not suitable for use in the bathroom. More expensive than pneumatic walkers.
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 Light

&easy to keep clean, can be removed for bathing &sleeping ,good for active Charcot joint &suitable for frequent dressing changes. Suitable for vascular patient &where swelling is present. Not good for non-compliant &oversize patients
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 Suitable

for elderly patients. Suitable for toe ulcers & forefoot ulcers. Can be used when other types of casts cannot be used. Can keep ulcers healed whilst waiting for special diabetic shoes to be made. Can be made removable for dressing changes
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2.

Improve blood flow by:

Arterial surgery:

Endarterectomy.

Arterial by pass. Trans luminal dilatation.

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3.

4. A. B. C. D.

Medical measures: exercise therapy, treatment of hypertension& hyperlipidaemia Give topical care Proteolytic enzymes e.g. collagenase, streptokinase. Antibacterial preparation. Macro-molecular dextran. Growth factor gel.
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5. 6.

Daily debridment of necrotic material and drainage of pus The use of tropical insulin have been suggested but it is of absolutely no value. Treatment of infection. Control of blood sugar level.

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 to

get the patient back to normal life as possible is another vital part of responsibility of treatment team.

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1. 2. 3. 4.

Toenails Corns/Calluses Xerosis Bunions/Hammertoes/other musculoskeletal problems

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5. 6. 7.

Vascular disease Neuropathy ULCERATIONS

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1. 2. 3. 4. 5.

Onychomycosis=Fungal nails Onychocryptosis=ingrown nail Onychogryphosis=thickened(Rams horn) nail Onycholysis=crumbly nail Onychia/Paronychia=abscessed/infected nail

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1. 2. 3. 4.

Location Cause Treatment Prevention

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CAUSE=PRESSURE
Usually a bony prominence

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MEASURES TO ELIMINATE PRESSURE POINTS 1. Podiatric consultation for debridement 2. Shoe modifications, insoles, orthotics 3. Elective surgery on deformity

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AKA-BUNIONS

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Indicators / Risk-factors for Recurrence:

Peripheral Arterial Disease Location of Index Ulcer
Plantar hallux ulcers more likely to recur or develop more ulcers Ulcers on the bottom of the foot more likely to recur Ulcers of the lesser toes usually located dorsally; less likely to recur
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