DIABETIC FOOT ULCER
SEMINAR 1
MBBS YEAR 4 OCTOBER 2015/2016
ROTATION 1- ORTHOPAEDICS
DEFINITION
International Consensus on Diagnosing and Treating
the Infected Diabetic Foot (2003)
Any infection involving the foot in a person with
diabetes originating in a chronic or acute injury to the
soft tissues of the foot, with evidence of pre-existing
neuropathy and/or ischemia.
RISK FACTORS
Neuropathy
Poor blood circulation (arterial diseases)
Uncontrolled diabetes
Wearing poor fitting footwear
Walking barefoot or any foot deformity.
Pathophysiology
Neuropathy
Motor
Damage to the innervations of the intrinsic
foot muscles
imbalance between flexion and extension
of the
affected foot
anatomic foot deformities that create
abnormal
bony prominences and pressure points
skin breakdown and ulceration
Pathophysiology
Neuropathy
Autonomic
Autonomic neuropathy
diminution in sweat and oil gland
functionality the foot loses its natural
ability to moisturize the overlying skin and
becomes dry and increasingly susceptible to
tears and the subsequent development of
infection
Pathophysiology
Neuropathy
Sensory
Patients are often unable to detect the
insult to their lower extremities
many wounds go unnoticed and
progressively
worsen as the affected area is
continuously
subjected to repetitive pressure and
shear
forces from ambulation and weight
bearing.
Pathophysiology
Vascular Disease
Peripheral arterial disease (PAD) is a contributing
factor to the development of foot ulcers.
It commonly affects the tibial and peroneal arteries of
the calf
PAD leads to occlusive arterial disease that results in
ischemia in the lower extremity and an increased risk
of ulceration in diabetic patients.
CHARCOTFOOT
is a condition causing weakening of the bones in the foot that
can occur in people who have significant nerve damage
(neuropathy). The bones are weakened enough to fracture,
and with continued walking the foot eventually changes
shape.
CLASSIFICATION
RISK FACTORS
Risk factors that are predictive and/or
precursors of DFU include direct and indirect
causes
Deformity, peripheral artery disease,
peripheral neuropathy, previous foot wound,
and/or a prior amputation are risk factors
predictive of new or recurrent DFU.
Lifestyle factors that contribute to DFU are smoking,
diabetes, malnutrition, immobility, older age, deficits
in cognitive function, lack of insight, and inability to
follow optimal management (such as lower extremity
elevation) because of other significant comorbidities
SYMPTOMS
Peripheral Neuropathy
Hypaesthesia
Hyperesthesia
Paresthesia
Dysesthesia
Radicular pain
Anhydrosis
Peripheral Insufficiency
Usually asymptomatic
Intermittent claudication
Ischemic pain at rest
Non-healing ulceration of the foot
Frank ischemia of the foot
INVESTIGATION
Full blood count
HbA1c
Renal Profile
Fasting blood sugar
Doppler studies and ultrasound
Imaging
INVESTIGATION
Transcutaneous oxygen pressures (TcpO2)
considered Gold Standard to assess wound healing potential
> 30 mm Hg (or 40mmHg depending on review source cited) is
a good sign of healing potential
ABI's and ischemic index
calcification in the arteries can result in inaccurate doppler flow
readings
calcifications falsely elevate the ABI's due to decreased
compliance of the calcified vessels
index of > 0.45 and toe pressure >40mm Hg are needed to
heal ulcer
Radiographs
recommended views :- AP, lateral, and oblique of foot
and ankle
MRI
best for differentiating abscess from soft tissue swelling
difficult to differentiate infection from Charcot
arthropathy on MRI
Bone scan
Views obtain with technetium Tc99m, gallium (Ga)67, or
indium (In) 111
useful to differentiate between soft tissue infection,
osteomyelitis, Charcot arthropathy
Treatment Protocol
General factors important in
deciding a treatment plan
include
angiopathic vs.
neuropathic
deep vs. superficial
+/- osteomyelitis,
antibiotics based on bone
biopsy culture sensitivities
NON OPERATIVE
Wound care
First line of treatment
Goals of wound care and dressings is to : provide moist environment
absorb exudate
act as a barrier
off-load pressure at ulcer
Total Contact Casting (TCC)
Gold Standard for mechanical relief plantar ulcerations
Has adequate blood supply and ability to monitor patient
at interval of 1-2 weeks
Contraindications
Absolute infection
marginal arterial supply to affected area
patients unable to comply with cast care
patients unable to tolerate a cast (cast claustrophobia)
Shoe modification
prevention when signs of potential ulcers are present
includes
deep or wide shoes, custom insoles, rocker bottom soles
(the best
to reduce plantar pressure on the forefoot)
Life style modification
Glucose to be kept under control
Blood pressure control
Lipid management
Smoking cessation
Care Guide
Foot Care :
1.Inspect your feet daily :
Check for cuts, blisters, redness, swelling, or nail
problems.
2.Wash your feet in lukewarm :
Keep your feet clean by washing them daily. Daily
dressings to keep wound clean and dry.
3.Appropriate footwear and socks :
Never walk barefooted, an injury can aggravate the
ulcer.
4.Moisturize the feet :
Use a moisturizer daily to keep dry skin from itching
or cracking.
5.Cut nails carefully :
Cut them straight across and file the edges
OPERATIVE
Surgical debridement, antibiotics, local wound
care, contact casting
Ostectomy
( TAL )
Indications :- bony prominence causing internal pressure
Technique :- TAL indicated if tight Achilles
effective to help heal and prevent recurrence of plantar
forefoot ulcers
Partial calcanectomy
Indications :- large heel ulcers with associated calcaneal osteomyelitis
Outcomes :- preserves limb length and decreases morbidity compared
to higher level amputations
Syme amputation
Indications :- forefoot gangrene and a palpable posterior tibial artery
pulse
REFERENCE
http://www.consultant360.com/articles/risk-factors-diabetic-foo
t-ulcers-first-step-prevention
http://clinical.diabetesjournals.org/content/24/2/91.full
