Diabetic Foot

Examination 1. Exposure - until the upper knee - examine both feet 2. Inspection a) Examination of the surrounding tissue redness, pale, bluish and congested oedema scar hard corns(hyperkeratosis over the bony prominence, caused by pressure against the shoe) soft corns(marcerated hyperkeratosis lesion between the toes not a/w pressure or friction) callosity fissure cellulitis(raised, erythematous, edematous, painful and warm) abscess scaly trophic changes(hair loss, brittle nails, skin shiny, dry, loss of tissue turgor) gangrenous changes veno-varicosity deformity i) fore foot: claw toe ii) mid foot: cavus foot, pes cavus iii) hind foot: valgus heel space between the toes: any fungal infection b) Examination of the ulcer - single/multiple - site - size - shape - surrounding skin/tissue: redness, swelling - margin regular/irregular well/ill-defined - edge slopping: healing punched out: non-healing undermined: chronic process(pyogenic, TB, amaebic) rolled: basal cell carcinoma - floor pale, pink or red healthy looking? granulation tissue(sign of recovery/healing) sloughed(pale, yellowish or greenish necrosed tissue) discharge(serous, seropurulent, purulent) exposed structures(bone, joint, tendon, neurovascular bundle) - depth 3. Palpation - temperature - tenderness(of the ulcer and surrounding skin) - consistency of surrounding skn

fixation

base - soft/firm/indurated(induration indicates fibrotic tissue underlying) - smooth/irregular - fluctuant(abscess, pus) - contact bleeding - press at edge(milk for pus) 4. Movement - toes - ankle 5. Neurovascular a) motor - tone - power - reflex(knee and ankle jerks) b) sensory - light touch - pain - vibration(first sensation to loss) - proprioception * look for grove and stocking distribution of sensory loss c) vascular - pulses(popliteal, posterior tibialis and dorsalis pedis arteries) - capillary refilling Approach and Assessment 1. determine the cause - neuropathy - ischaemic - combination Neuropathic ulcer 1. dependant and pressure area: metatarsal head, heel and ball of the foot 2. 3. 4. 5. 6. 7. 8. deformity(e.g.claw foot) pink surrounding skin distended vein callosities and fissures painless foot is warm ulcer base: bleeds easily

9. palpable pulses 10. complications: - painless ulceration - infected ulcer - callosities - digital gangrene - Charcoats joint - Neuropathic oedema

Ischaemic ulcer 1. distal part: medial surface of 1st metatarsal head, lateral surface of 5th metatarsal head, tips of toes 2. gangrenous digits 3. pale surrounding skin 4. trophic changes 5. skinny 6. painful to touch 7. cold foot 8. ulcer base: dull fibrotic and no bleed easily 9. weak or absent pulses 10. complications: - painful ulceration - claudication - digital gangrene

* venous ulcer bloated, edematous; usually at medial malleolus 2. determine the stage(by Meggit-Wagner Classification)

3. determine whether is the lesion complicated by infection(cellulitis, abscess or osteomyelitis) Characteristics of Diabetic Foot Infection 1. polymicrobial - aerobes: S.aureus, Streptococci, Coliform - anaerobes: Bacteroides spp. 2. very notorious(does not respect tissue plane can involve whole fascia) 3. chronic in nature and relatively resistant to treatment(healing process is abnormal) Meggit-Wagner Classification - based on depth ofulcer, presence osteomyelitis and severity of gangrene Stage 0: No ulcer; present of risk factors(e.g. foot deformities, sensory neuropathy, previous Hx.of foot ulcer, blind/partially sighted) Stage 1: Superficial ulcer, skin deep(full thickness of skin loss) Stage 2: Deep ulcer usually with infection/cellulitis; no bone involvement Stage 3: Infected deep ulcer with osteomyelitis and abscess formation Stage 4: Ulcer with gangrene of hindfoot(digits) Stage 5: Ulcer with gangrene of forefoot Pathophysiology - multifactorial - 3 main causes: A) polyneuropathy a. motor - weakness of the intrinsic muscles imbalance between the flexors and extensors deformities such as cavus foot, claw toes unusual and uneven pressure distribution repeated trauma b. sensory - loss of pain sensation unaware of noxious stimuli and unable to avoid trauma continuous pressure on a particular pressure area(repetitive stress and high pressure injury hard callosities) - loss of proprioception sensation ataxia and prone to fall c. autonomic - reduced sweating dry skin fissures and cracks portal of entry for microorganisms - loss of microcirculation autoregulation loss of normal hyperaemic response needed to fight the infection B) peripheral vascular disease compromised blood supply poor immune mechanism and wound healing ischaemia devitalised tissue prone to infection C) infection high glucose content culture medium for microorganisms high glucose content reduced chemotactic phagocytosis of inflammatory cells Investigations - 4 important investigations: i) wound swab for microbiological examination + culture & sensitivity(if abscess present aspiration) ii) random blood sugar or fasting blood sugar(assess blood sugar control) iii) foot x-ray(look for osteomyelitis and charcots joint) iv) ankle-brachial systolic index(by Doppler u/s probe)

- important esp. for ischaemic cause and serious infection - normal: 1.0 - > 0.45 is necessary for ulcer healing(wound healing will depend directly on the local blood flow) - < 0.5: impending gangrene - < 0.3: amputation may be needed other investigations: - blood culture - FBC - BUSE - screen for other complications of diabetic mellitus

Management - depends on the grading: A) Grade 0 - mainly prophylaxis: a) foot care - foot hygiene - wear sock s or stockings - footwear should be well fitting with soft and pliable uppers - nails should be transversely at the centre - daily inspection of accidental damage to feet - corns and callosities should be treated by a chiropodist - never walk bare-footed b) patient education - diabetic control(diet, compliance and follow-up) - stop smoking( peripheral vascular disease) c) corrective surgery for deformities - to relieve pressure over potential breakdowns areas B) Grade 1, 2 and 3 1. Control the infection a) local - abscess drainage and dressings - removing mechanical forces(neuropathic ulcer can only be healed if the mechanical forces are removed): i. strict bed rest ii. non weight-bearing on crutches iii. total contact cast invaluable for the Mx of plantar ulcer for grade 1 and 2 ulcers not used in ischaemic ulcers(made the condition worse) the ulcer is debrided and excess callus is removed before the cast application below knee plaster cast applied with minimal padding for a bony prominence it provides equal distribution of forces along the plantar surface of the foot a rigid compression dressing to control swelling ans oedema a protective covering to compensate for the lack of sensation - surgical debridement of infected ulcer and necrotic tissue - surgical revascularization(vascular reconstruction) of the ischaemic foot - skin graft(grade 1) - sometimes may need local amputation(grade 3)

systemic antibiotics: cloxacillin metronidazole(Flagyl) gentamicin 2. Control the blood sugar diet control oral hypoglycaemic agents(OHA) insulin(may shift from OHA to insulin to have proper blood sugar control) C) Grade 4 and 5 - grade 4: a) local amputation - if ABI >0.45 and gangrene is dry and limited to distal portion of toe b) ray amputation - if gangrene is wet and progressive c) below-knee, through-knee or above-knee amputation - if ABI has not been high enough for distal amputation - grade 5: local pocedures not adequate below-knee, through-knee and even above-knee amputation as indicated by vascular status -

b)