Title slide

How you should

study this module
Learning outcomes
Epidemiology
Pathophysiology
Section one quiz
Assessment
Section two quiz
Management
Section three quiz
Information
sources
Nice pic, but why is this module
important?

Well, in 2007, 246million
people aged 20 - 79 years were
diagnosed with diabetes mellitus
a global epidemic affecting 6%
of the adult population.
25% of these develop foot
problems...thats 61.5 million
diabetic feet!
And, worryingly, the prevalence
of diabetes mellitus is expected
to reach 333 million by 2025.

For information on the
authors and reviewers
click here
The foot of a diabetic patient showing
extensive tissue necrosis and infection
WELCOME TO THE DIABETIC FOOT MODULE!
Page 1 of 67
Diabetic Foot
Title slide
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study this module
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Epidemiology
Pathophysiology
Section one quiz
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Management
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Information
sources
How should you study this module?
1. We suggest that you start with the learning objectives and try
to keep these in mind as you go through the module slide by
slide.
2. Print out the mark sheet.
3. As you go along, write your answers to the questions on the
mark sheet as best you can before looking at the answers.
4. Award yourself marks as detailed on the mark sheet: one
mark for each keyword (shown in the red text) in the short
answer questions and for every correct answer in the
True/False questions.
5. Repeat the module until you have achieved a mark of > 80%
(65/81)
6. Finish with the formative multiple choice questionnaire to
assess how well you have covered the materials as a whole.
7. You should research any issue that you are unsure about.
Look in your textbooks, access the on-line resources indicated
at the end of the module and discuss with your peers and
teachers.
8. Finally , enjoy your learning! We hope that this module will be
enjoyable to study and complement your learning about
diabetic foot from other sources.
Page 2 of 67
Title slide
How you should
study this module
Learning outcomes
Epidemiology
Pathophysiology
Section one quiz
Assessment
Section two quiz
Management
Section three quiz
Information
sources
By the end of the module, you should be able to:
1. Discuss the global burden of the diabetic foot in
both the developing and developed world
2. List the causes of diabetic foot ulceration then
fully assess for each one and their complications;
using bedside examinations, blood tests,
microscopy and radiology
3. Discuss the management of diabetic foot ulcers
using
i. mechanical intervention (debridement, dressing and
cast application)
ii. invasive treatment (larvae, antimicrobials and
amputation)
iii. analgesia
4. Offer advice to diabetic patients on proper foot
care and footwear for prevention of foot problems

Page 3 of 67
Learning Outcomes
Title slide
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study this module
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Epidemiology
Pathophysiology
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Section two quiz
Management
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So how many people with diabetes are there?
Here are recent estimates of the disease burden due to diabetes and
projections for the future.
2003 2025
Europe Africa Europe Africa
Population
Total
Adult
(20-79 yrs)

872 million

621 million

667 million

295 million

863 million

646 million

1107 million

541 million
Diabetes
No. of people
(20-79 yrs)
Prevalence
(20-79 yrs)


48.4 million

7.8 %


7.1 million

2.4 %


65 million

7.8 %


19million

4.3 %
Source: International Diabetes Federation and The international Working Group on Diabetes
joint publication 2006.
Page 4 of 67
Epidemiology 1
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Epidemiology
Pathophysiology
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Thats a lot! How many of these get foot ulcers?
Developed countries: 15% of people with diabetes get ulcers at least once in
their lifetime
Developing countries: the prevalence is even higher at 20%.
...and does amputation use vary from place to place? Yes!...see below;





Incidence of minor and major amputations per 1000 people with diabetes
Incidence
per 1000
Population Year
Mauritius 680 Hospital-oriented 1998-2002
Tanzania 400 Hospital-oriented 2002
Croatia 6.8 Hospital-oriented 2002
UK 2.6 Regional 1998
The Netherlands 3.6 Nationwide 1991-2000
Source: International Diabetes Federation and The international Working Group on Diabetes joint
publication 2005.
Page 5 of 67
Epidemiology 2
Title slide
How you should
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Epidemiology
Pathophysiology
Section one quiz
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Section two quiz
Management
Section three quiz
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sources
According to the above data;

1. Which region has the most people with
diabetes?


2. Which region will see the greatest
increase in diabetes prevalence by
2025 ?

3. Which region has the greatest disease
burden due to diabetic foot ?
Click the box for the
correct answer
1
2
3
Page 6 of 67
Epidemiology Quiz
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Epidemiology
Pathophysiology
Section one quiz
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Management
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sources
How does the diabetic foot affect individuals
and society?

Diabetic foot ulcers and their complications
(explained later) are often painful. Patients often
become dependent on others for mobility.
As a result, patients suffer a loss of autonomy and
reduced social function, making depression
common.

The cost of diabetic foot management is 12-15% of
the total healthcare budget for diabetes in developed
countries. This figure may as high as 40% in
developing countries*. These figures do not account
for the cost of the loss of potential working members
to the economy and the social costs of the inability to
support a family.

*IDF/IWG joint publication on diabetic foot.
Page 7 of 67
Epidemiology 3
Title slide
How you should
study this module
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Epidemiology
Pathophysiology
Section one quiz
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Section two quiz
Management
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sources
Well those diabetic feet are everywhere and causing
chaos! If were going to stop them, I would first like to
know how diabetic foot ulcers occur

Diabetic foot ulcers may have multiple causes, the
prominent ones being;

A. Peripheral neuropathy (nerve damage)

B. Peripheral vascular disease (poor pedal blood
supply)

C. Trauma

i. Acute: any injury to the foot such as burns or cuts

ii. Chronic: due to foot deformities (changes of foot shape
that lead to ill-fitting shoes and, thereby, ulceration)
Page 8 of 67
Pathophysiology
Title slide
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Epidemiology
Pathophysiology
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Management
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sources
Neuropathy
Motor Sensory Autonomic
nociception
Proprioception,
Unawareness
of foot position
A-V Shunt* open
Permanent
Increase foot
Blood flow
Bulging foot veins,
Warm foot
Reduced
sweating
Dry skin
Fissures and
cracks
Muscle wasting
Foot weakness
Postural deviation
Deformities, stress
and shear pressures
*Shunts: blood vessels that bypass capillaries and lead directly from arteries to veins
Trauma
Stress on bones & joints
Plantar pressure

Callus formation

Infection
Ulcer
Page 9 of 67
Pathophysiology Neuropathy
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Then how are blood vessels
affected?
High blood sugar expedites
artherosclerosis giving peripheral
vascular disease (reduction of blood
supply to the foot).
The delivery of essential nutrients
and oxygen to the foot is
compromised leading to anaerobic
infections and tissue necrosis.
Peripheral arterial disease
Artherosclerosis
narrows or blocks
the arterial lumen
Foot ischaemia
Foot ulcer
Necrosis/ Gangrene
Infection
Artheroma plaque
narrowing the arterial
lumen
Ischaemic toes due to
artherosclerosis
Page 10 of 67
Pathophysiology Peripheral Arterial Disease
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Dont people with diabetes feel trauma before it
reaches ulceration stage? No- thats the
problem!

Acute trauma: abrasions and burns occur often due
to the absence of nociception. Poor wound
healing makes ulcerations more likely occur.

Chronic trauma: reduced motor function results in a
high arch. Together with decreased
proprioception, this creates classical deformed
foot shapes (explained later). These result in
bony prominences which, when coupled with
high mechanical pressure on the overlying skin,
results in ulceration.
Page 11 of 67
Pathophysiology Trauma
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Well done!
You have come to the end of the first section






We suggest that you answer Question 1 to 4 to
assess your learning so far. Please remember to
write your answers on the mark sheet before
looking at the correct answers!
Page 12 of 67
End of Section 1
Title slide
How you should
study this module
Learning outcomes
Epidemiology
Pathophysiology
Section one quiz
Assessment
Section two quiz
Management
Section three quiz
Information
sources
Question 1: write T or F on the answer sheet. When you have
completed all 5 questions, click on the boxes and mark your
answers.
a) Diabetic foot is a global health problem


b) The prevalence of diabetes is falling


c) The incidence of foot ulcers in people with
diabetes is higher in developed than developing
countries


d) Diabetic foot amputation is commoner in
developing countries than developed countries


e) Post amputation mortality is higher in developed
countries
a
b
c
d
e
Page 13 of 67
Section 1 Quiz
Title slide
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study this module
Learning outcomes
Epidemiology
Pathophysiology
Section one quiz
Assessment
Section two quiz
Management
Section three quiz
Information
sources
Question 2: write T or F on the answer sheet. When you have
completed all 4 questions, click on the boxes and mark your
answers.

a) Diabetic foot problems result in a higher
cost to the economy in developing than
developed countries

b) Depression is common in diabetic foot
patients

c) Wound healing is slower in diabetes

d) Artherosclerosis is common in diabetes
patients



a
b
c
d
Page 14 of 67
Section 1 Quiz
Title slide
How you should
study this module
Learning outcomes
Epidemiology
Pathophysiology
Section one quiz
Assessment
Section two quiz
Management
Section three quiz
Information
sources
Question 3: The 4 main causes of diabetic foot ulcers
are; write the answers in your mark sheet.
a) Peripheral neuropathy

b)

c) Peripheral arterial disease

d)
Click here for the
answers
Section 1 Quiz
Title slide
How you should
study this module
Learning outcomes
Epidemiology
Pathophysiology
Section one quiz
Assessment
Section two quiz
Management
Section three quiz
Information
sources
Question 4: Study this flow chart and list 4 factors that predispose to
diabetic foot ulceration. Write your answer in your mark sheet
Neuropathy
Motor Sensory Autonomic
nociception
Proprioception,
Unawareness
of foot position
A-V Shunt* open
Permanent
Increase foot
Blood flow
Bulging foot veins,
Warm foot
Reduced
sweating
Dry skin
Fissures and
cracks
Muscle wasting
Foot weakness
Postural deviation
Deformities, stress
and shear pressures
*Shunts: blood vessels that bypass capillaries and lead directly from arteries to veins
Trauma
Stress on bones & joints
Plantar pressure

Callus formation

Infection
Ulcer
Click here for
the answers
Page 16 of 67
Section 1 Quiz
Title slide
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study this module
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Epidemiology
Pathophysiology
Section one quiz
Assessment
Section two quiz
Management
Section three quiz
Information
sources
How do we predict how bad a diabetic foot is then?

Foot assessment needs to be undertaken in all people with
diabetes to evaluate the individuals risk of foot
complications and hence plan management.

It can be undertaken by a podiatrist, junior doctor,
specialised diabetes nurse or other trained nurses.

The aim of the assessment is to examine each pathological
cause that creates ulcers:
1) peripheral neuropathy
2) peripheral arterial disease
3) structural
But how do you assess the diabetic foot? Let me guess.
As always start with the history and then the
examination for each cause ?- Bingo!
Page 17 of 67
Assessment
Title slide
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study this module
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Epidemiology
Pathophysiology
Section one quiz
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History
burning, tingling, numbness of the foot
and nocturnal leg pain indicate
cutaneous sensory deficits
Note that in ~35% of patients who are
asymptomatic, neuropathy can be
detected by examination

Examination
Inspect deformities such as claw toes,
hair loss, muscle atrophy and a high
medial longitudinal arch (giving
prominent metatarsal heads)
Test for reduced power and reflexes that
are evidence of muscular motor deficits.
Test sensation by skin pinprick
(spinothalamic tracts), proprioception
and vibration (dorsal columns)
Claw toes
Prominent metatarsal
heads and an ulcer
Page 18 of 67
Assessment Peripheral Neuropathy
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Epidemiology
Pathophysiology
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Management
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Place a 10g nylon Semmes-Weinstein
monofilament at a right angle to the skin
Apply pressure until the monofilament
buckles, indicating that a specific
pressure has been applied.
Inability to perceive the 10g of force
applied by the monofilament is
associated with clinically significant
large fibre neuropathy and an increased
risk of ulceration (sensitivity of 66 to
91%)
Test 4 plantar sites on the forefoot
(great toe and the base of 1
st
, 3
rd
and
5
th
metatarsals ) to identify 90% of
patients with an insensate foot.
Monofilament test
Page 19 of 67
Assessment Monofilament for pressure sensation (pinprick sense)
Title slide
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study this module
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Epidemiology
Pathophysiology
Section one quiz
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Section two quiz
Management
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Apply a vibrating 128 Hz tuning fork
to the bony prominence of the big
toe
If the patient cannot feel the
vibration, gradually move the fork
upwards
The sensitivity of this test for
demonstrating a deficit is ~53%
A biothesiometer is a portable
device that measures the vibration
perception threshold. A vibration
threshold of more than 25V has a
sensitivity of 83%.
Tuning fork
test
Either an abnormal 10g monofilament test or a vibration
threshold of more than 25V predicts foot ulceration with
a sensitivity of 100% , hence the rationale for combining
these two tests in clinical practice.
Page 20 of 67
Assessment Tuning Fork (vibration)
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Epidemiology
Pathophysiology
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So how do we know how well the blood is flowing?
History : claudication (calf pain after walking a specific distance) that
is relieved by rest. However this is uncommon in people with diabetes
due the concomitant neuropathy.
Examination: Palpate the foot for temperature (cool in PVD); palpate
the dorsalis pedis pulse and, if absent, the posterior tibial pulse. Test
for Bergers angle (at which leg turns white) and reactive hyperaemia
(leg turns bright red on declining back to the ground).



Palpation of the dorsalis pedis pulse Palpation of the posterior tibial pulse
Page 21 of 67
Assessment Peripheral Vascular Disease (PVD)
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Epidemiology
Pathophysiology
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Measure the blood pressure (BP) in the
arm using a sphygmanometer
Measure the blood pressure in the foot.
Place a BP cuff around the calf and detect
the dorsalis pedis pulse using a small
hand-held doppler. Inflate the cuff and
slowly deflate until the pulse appears.
The ankle brachial pressure index (ABPI) is
the ratio of the ankle systolic pressure to
brachial systolic pressure.

ABPI is usually >1 but in the presence of
peripheral vascular disease is <1. Normal
ABPI effectively excludes significant
arterial disease in >90% of limbs.
Doppler being used to detect
the dorsalis pedis pulse
Absence of pulses and an ABPI of <1 confirms significant
ischaemia. An exception is in medial artery calcification, in
which the ABPI can be falsely elevated due to the
simultaneously lower blood pressure (BP) in the upper limb.
Page 22 of 67
Assessment Investigations: ankle brachial pressure index
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Epidemiology
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Structural abnormalities and deformities lead
to bony prominences which are associated
with high mechanical pressure on the
overlying skin.
This results in ulceration, particularly in the
absence of a protective pain sensation and
when shoes are unsuitable.
Ideally, the deformity should be recognised
early and accommodated in properly fitting
shoes before ulceration occurs.

Common abnormalities / deformities include:
i. Callus
ii. Bunion
iii. Hammer toes
iv. Claw toes
v. Charcot foot
vi. Nail deformities

Note: It is vital to inspect the patients
shoes as part of the assessment!
Callus on plantar surface
Bunion on the medial
border of the foot
Page 23 of 67
Assessment Structural Abnormalities and Deformities
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Claw toes
Charcot foot
deformity
Nail deformity
Page 24 of 67
Assessment Some Common Foot Deformities
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Several foot ulcer classifications
have been proposed although none
is universally accepted.
The simplest classification is based
on the underlying pathogenesis:
neuropathic, ischaemic or
neuroischaemic.
It is vital to carefully monitor the
progress of an ulcer once one has
developed.
The University of Texas system
shown on the next slide can be used
to predict outcome by grading
wound depth and presence of
infection and/or ischaemia.
However there is no measure of
neuropathy.

A neuropathic ulcer on
the sole of the foot
Pre-ulcer assessment all done! What about after an ulcer
has developed?
Page 25 of 67
Assessment Ulcers
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Ulcer Grade ( depth )
0 I. II. III.
Ulcer
stage
A Pre / postulcerative
lesion completely
epethelialised
Superficial
lesion, not
involving tendon,
capsule or bone
Wound
penetrating to
tendon or
capsule
Wound
penetrating to
bone or joint
B Pre / postulcerative
lesion with
Infection
Superficial
lesion, not
involving tendon,
capsule or bone
with Infection
Wound
penetrating to
tendon or
capsule with
Infection
Wound
penetrating to
bone or joint
with Infection
C Pre / postulcerative
lesion with
ishaemia
Superficial
lesion, not
involving tendon,
capsule or bone
with ischaemia
Wound
penetrating to
tendon or
capsule with
ishaemia
Wound
penetrating to
bone or joint
with ishaemia
D Pre /postulcerative
lesion with
infection and
ishaemia
Superficial
lesion, not
involving tendon,
capsule or bone
with infection
and ischaemia
Wound
penetrating to
tendon or
capsule with
infection and
ishaemia
Wound
penetrating to
bone or joint
with infection
and ishaemia
Page 26 of 67
Assessment University of Texas system for classification of ulcers
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How do you know if the ulcer is infected then?
Assessing foot ulcers for the presence of infection is vital. All
open wounds are likely to get colonised with microorganisms,
such as Staphylococcus aureus, and not necessarily infected.
Therefore, the presence of infection needs to be defined
clinically rather than microbiologically.
An infected ulcer
Signs suggesting
infection include;
1. purulent
secretions
2. presence of friable
tissue
3. undermined edges
4. foul odour

Page 27 of 67
Assessment Infected Ulcers
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Simple investigations include:
Tissue specimens or material obtained from the bottom of a
wound for gram staining and culture for microbial sensitivity.
Aspiration of material for culture is better than taking a swab
which is prone to contamination.
Full blood count, urea and electrolytes, inflammatory markers
(WCC, ESR and CRP) for assessing severity of infection
Plain X-ray of the leg for signs of bone damage, presence of
foreign body, or gas in soft tissue (gas gangrene)

More advanced radiology involves:
Technetium bone scan and MRIs may be necessary in some
patients to define underlying bony involvement

Invasive investigations include:
Bone biopsy, as the gold test for diagnosing osteomyelitis.
Arteriography using contrast dye can be used to visualise leg
ischaemia
Page 28 of 67
Assessment Infected Ulcers: Investigations
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Well done!
You have come to the end of the second section






We suggest that you answer Questions 5 to 9 to
assess your learning so far. Please remember to
write your answers on the mark sheet before
looking at the correct answers!
Page 29 of 67
End of Section 2
Title slide
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Epidemiology
Pathophysiology
Section one quiz
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Section two quiz
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Section three quiz
Information
sources
1) ..
2) ..
3) ..
Question 5: List the 3 components of diabetic foot
assessment. Write your answer in your mark sheet
Click here for the
answers
Page 30 of 67
Section 2 Quiz
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Epidemiology
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a) A high medial longitudinal arch and prominent
metatarsal heads are signs of ischaemia

b) The tuning fork and biothesiometer are used for
assessing pressure sensation

c) Ankle brachial pressure index is the ratio of ankle
systolic pressure to brachial diastolic pressure

d) A doppler can be used to confirm the presence of
pulses but cannot quantify the vascular supply

e) Bone biopsy is the gold standard for diagnosing
osteomyelitis
Question 6: Write T or F on the answer sheet. After
completing all 5 questions, click on the boxes and mark
your answers.
a
b
c
d
e
Page 31 of 67
Section 2 Quiz
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Question 7: Identify these clinical images. Write your answer in your
mark sheet
Click here for the
answers
1
4
2
Page 32 of 67
Section 2 Quiz
3
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I.
II.
III.
IV.
V.
Question 8: List 5 common foot deformities found in
association with diabetic feet. Write your answers on
the mark sheet.

Click here for the
answers
Page 33 of 67
Section 2 Quiz
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Question 9: Fill in the blanks in the University of Texas grading and
staging table. Write your answer in your mark sheet

Ulcer Grade ( depth )
0 I. II. III.
Ulcer
stage
A
Pre / postulcerative
lesion completely
epethelialised
Superficial
lesion, not
involving tendon,
capsule or bone
Wound
penetrating to
tendon or
capsule
Wound
penetrating to
bone or joint
B
Superficial
lesion, not
involving tendon,
capsule or bone
with Infection
Wound
penetrating to
bone or joint
with Infection
C
Pre / postulcerative
lesion with
Ishaemia
Wound
penetrating to
tendon or
capsule with
Ishaemia
D
Pre /postulcerative
lesion with
Infection and
Ishaemia
Superficial
lesion, not
involving tendon,
capsule or bone
with Infection
and Ischaemia
Wound
penetrating to
tendon or
capsule with
Infection and
Ishaemia
Wound
penetrating to
bone or joint
with Infection
and ishaemia
Page 34 of 67
Section 2 Quiz
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Ok, so now we know the extent of the problem, how it
occurs and how to assess for it. Now what do we do
about it?

General measures
Managing diabetes and its complications requires a
multidisciplinary approach because
optimum glycaemic control is key in reducing all
complications
cardiovascular risk factors such as smoking,
dyslipidaemia and hypertension should be
addressed to reduce risks of PVD, acute coronary
syndrome and chronic renal failure
education of patients on proper foot care and on the
importance of seeking medical advice early is very
important
Page 35 of 67
Management
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Pathophysiology
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If a patient with diabetes has normal feet do we need to worry?...YES!
Your aim is to keep the foot normal. Key elements are:
wearing the correct footwear
the diagnosis and prompt treatment of foot problems that are common in the general
population including people without diabetes.

Good shoe guide:
Toe box should be sufficiently long, broad and deep to accommodate the toes without
pressing on them, with a clear space between the apices of the toe the toe box
Shoes should be fasten with adjustable lace, strap or Velcro high on the foot in order to hold
foot firmly inside the shoe and thus reduce frictional forces when the patient walks
The heel of the shoe should be less than 5 cm to avoid weight being thrown forward into
metatarsal heads
The inner lining of shoe should be smooth
Stocking or socks should always be worn to avoid blisters


Good pairs of shoes for men and women An example of a bad
shoe type
Page 36 of 67
Management The Normal Foot
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Most people in this stage will be able to cut their
own toe nails. However specific nails and other
minor foot problems will need treatment from
the podiatrist. These are the most common
conditions:
Onychogryphosis (rams horn nail); regular
debulking by a podiatrist
Onychocryptosis (ingrowing toe nail); removal
of the offending nail splinter and filing of the
ragged edge by a podiatrist
Involuted toe nail; clearance of the sulcus with
a Blacks file (specially design for it)
Onychomycosis; reduce bulk of the nail at
regular intervals, treat with antifungals
Tinea pedis (athletes foot); treat with topical
antifungals (e.g canesten).
Verrucae (warts); treat by cryotherapy. Most
resolve within 2 years.
Corns; removal by a podiatrist.
Nail cutting
Athletes foot
Page 37 of 67
Management Diagnosing and treating common foot problems
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Deformities should be accommodated in
properly fitting footwear. Special footwear
will be needed if the deformity is severe.
Some specific deformities need special
management;
Clawed toes need a shoe with a wide,
deep, soft toe box to reduce pressure on
the dorsum of the toes. Extra depth
shoes to protect the apices of the toes
Prominent metatarsal heads: an extra
depth stock shoe with a cushioning insole
may suffice
Callus: Is the most important pre-ulcerative
lesion in this stage. It should be regularly
and sufficiently remove by a podiatrician
with a scalpel.
Dry skin and fissure: treat with an
emolient (E45 or calmurid cream), reduce
fissure margins with scalpel
Callus removal
And if neuropathic or ischaemic and/ or deformities
are present? - This foot is susceptible to ulcers, so...
Page 38 of 67
Management The At-Risk Foot
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If PAD is evident:
address cardiovascular
risk factors
smoking
dyslipidaemia
hypertension
treat with oral aspirin
75mg OD
seek advice from a
vascular surgeon if
available

Palpation of the dorsalis pedis pulse
Note: Vascular assessment is also needed before
cutting nails/calluses to ensure that wound healing
is adequate.
Page 39 of 67
Management Peripheral Arterial Disease (PAD)
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How should we advise patients that get
deformities?
Provide patients with the following
information:
Never walk bare footed
Visit a podiatrist regularly if you have
callus
Never try to remove corns or callus by
yourself
Prevent dryness in your feet by using
creams
Be careful not to burn your feet
Shake out loose pebbles or grit before
you put on your shoes
Run a hand around the sides of the
shoes to detect rough, worn places
Repair or replace worn out shoes

Claw toes
Page 40 of 67
Management Foot Deformities
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Its an ulcer..what now!?-Dont panic, be methodical.
Treatment of diabetic foot ulcers largely depends on the
underlying causes: ischaemia, neuropathy or a combination of
both. Treatment approaches for ischaemia include:

Ischaemic necrosis of a
toe and an extensive
plantar ulcer
Medical: reduce cardiovascular risk
factors (see above)

Surgical: revascularisation to achieve
timely and durable wound healing is
sometimes necessary. Patients with
supra-inguinal (aorta-iliac) disease may be
amenable to angioplasty (+/- stenting),
with good long-term results being
achieved at a low risk. Open bypass
surgery may be considered for those
patients who do not have an endovascular
option.

Page 41 of 67
Management Ulcers due to Ischaemia
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The best method is some form of cast
(see later) .
If not available, temporary ready-made
shoes with a plastozote insole such as
Drushoe can off-load the site of
ulceration. Alternatively, weight-relief
shoes and felt pads may also be used.
Other weight-relieving measures such
as the use of crutches, wheelchairs and
zimmer frames should be encouraged.
Heeled ulcers also need off-loading by
foam wedges, heel protector splints or
rings.

The common site for
a neuropathic ulcer
The key to treatment here is to redistribute plantar
pressure.

When the neuropathic ulcer has healed, it is vital that the patient is
fitted with a cradled insole and bespoke shoes to prevent recurrence.
Page 42 of 67
Management Ulcers due to Neuropathy
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These cast things sound useful...what are
they?
Various casts are available and all aim to relieve plantar
pressure. Their use is governed by local experience and
expertise

Air cast (walking brace)
A bivalved cast with the halves joined together with Velcro
strapping. The cast is lined with 4 air cells which can be
inflated with a hand pump to ensure a close fit. The cast
can be removed easily by patients to check their ulcers
and before going to bed.

Scotch cast boot
A simple, removable boot made of stockinette, soffban
bandage, felt and fibreglass tape.

Total contact cast
It is a close-fitting plaster of paris and fibreglass cast
applied over minimum padding. It is very efficient method
of redistributing plantar pressure, and should be reserved
for plantar ulcers that have not responded to other casting
treatments.
An air cast
A scotch cast boot
Page 43 of 67
Management Offloading Pressure: Casts
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Casts should be removed every week for wound inspection and
then renewed. Once the ulcer is healed, the patient should
be assessed for cradled insoles and bespoke shoes.
Cast problems to be aware of:
Iatrogenic lesions (rubs, pressure sores, infections) which
often go undetected
Cast are often heavy and uncomfortable and reduce the
patients mobilty
Patients may not drive a car in a cast
The leg may develop immobilisation osteoporosis
Danger of fracture and the development of a Charcot foot
when coming out of a cast if patient walks too far too soon
A few patients develop a cast phobia and will not wear them
Page 44 of 67
Management Casts: Some Precautions
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What can we do to treat the ulcer?
In both isacheamic and neuropathic ulcers, treatment is based on debridement of the
wound and dressing application.
Debridement is the removal of necrotic
and dead tissue in order to enhance
healing.
Debridement is undertaken to:
Remove callus in neuropathic foot to
lower plantar pressure
Assess the true dimension of the
ulcer
Drain exudate and remove dead
tissue to render infection less likely
Take a deep swab for culture
Encourage healing and restore a
chronic wound to an acute wound

Forcep and a scalpel is the
usual technique by cutting
away of all slough and non-
viable tissue.
Page 45 of 67
Management Wound Debridement
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The larvae of the green bottle fly (which feed on dead flesh) are
sometimes used to debride ulcers, especially in the ischaemic
foot. Only sterile maggots obtained from a medical maggot farm
should be used!
Maggots produce a mixture of proteolytic enzymes that breakdown
slough and necrotic tissue which they ingest as a source of
nutrients. During this process, they also ingest and kill bacteria
including antibiotic resistant strains.
As a result of their wound cleansing activity, the application of
maggots has been found to reduce wound odour, and it has also
been reported that their presence within a wound stimulates the
formation of granulation tissue.

Contra-indications to maggot therapy:
Free range maggots should not be introduced into wounds that
communicate with the body cavity or any internal organ
They should not be applied to wounds that have a tendency to
bleed easily or contain exposed large blood vessels
They should not be applied to patients with clotting disorders, or
individuals receiving anticoagulant therapy unless under
constant medical supervision in a health facility.


Page 46 of 67
Management Wound Debridement using maggots (larvaetherapy)
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Maggots are available in 2 forms.
1. Free Range maggots
applied directly to the wound
roam freely over the surface seeking
out areas of slough or necrotic
tissue
generally left on wound for a
maximum of 3 days.
2. BioFOAM Dressing
Maggots enclosed in net pouches
containing pieces of hydrophilic
polyurethane foam
dressing is placed directly upon the
wound surface
BioFOAM Dressing can be left for up
to 5 days then the wound is
reassessed.




BioFOAM dressing with
maggots inside
Page 47 of 67
Management Larvaetherapy Preparations
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A sterile, non-adherent dressing should cover all open diabetic foot lesions
to protect them from trauma, absorb exudate, reduce infection and promote
healing.

Dressings should be lifted every day to ensure that problems or
complications are detected quickly, especially in patients who lack
nociception.

Additional approaches include

Skin graft:
A split-skin graft may be harvested and applied to the ulcer to speeds healing of
the ulcer which if has a clean granulating wound bed

Vacuum-Assisted closure (VAC) pump:
This is an innovative measure to close diabetic foot wounds. It applies gentle
negative pressure to the ulcer via a tube and foam sponge which are applied to
the ulcer over a dressing and sealed in place with a plastic film to create a
vacuum. Exudate from the wound is sucked along the tube to a disposable
collecting chamber. The negative pressure improves the vascularity and
stimulates granulation of the wound.


Page 48 of 67
Management Wound Dressings
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Are there any new interesting aids for wound healing? Yes, three here;
Hyperbaric oxygen therapy: Poor tissue oxygenation with diabetic
microangiopathy reduces wound healing. Therefore hyperbaric oxygen
therapy (HBOT) would theoretically aid in faster wound healing, there is
however little evidence for this at present.

Growth factor therapy: Recombinant platelet derived growth factor
(PDGF) was the first growth factor approved by the Food and Drug
Administration (FDA) for the treatment of lower extremity diabetic
neuropathic ulcers that extend into the subcutaneous tissue and have
adequate blood supply. PDGF, applied as a gel , theoretically acts to
enhance granulation tissue formation and facilitate epithelialisation . It may
be useful in small, low-grade so may have a role in chronic neuropathic
ulcers that are refractory to conventional therapy but there is no evidence
to support this theory.

Bioengineered human dermis transplantation: Dermagraft is a cultured
human dermis produced by seeding dermal fibroblasts on a biodegradable
scaffold. After culture, a living dermal tissue is created which can later
support the formation of an epidermis. Furthermore, dermatograft can
generate growth factors, cytokines, matrix proteins and
glycosaminoglycan, thus aiding the healing process. There have been a
limited number of trials have confirmed the efficacy of dermagraft in
healing chronic ulcers in a significantly shorter time.

Page 49 of 67
Management New Developments
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It appears infected...which antibiotics to use?
Treating infected ulcers:
Ensure the previously described physical wound management techniques are used.
The initial antibiotic regime is usually selected empirically based upon clinical
experience and local preferences; cover of +cocci is essential as they are the usual
culprits of infection as they thrive cutaneously. Antibiotics are modified on the basis of
clinical response and and wound culture / sensitivity results. Good examples include;


Oral antibiotics Perenteral antibiotics
Penicillin V OR co-amoxiclav +/- Benzylpenicillin +/-

Flucloxacillin
Ciprofloxacillin
Cephalexin
clindamycin
Flucloxacillin
Imipenem-cilastin
Ampicillin-sulbactam
Cefuroxime
Metronidazole ( for anaerobes )
For mild infections, 7-10 day course is usually sufficient. Severe infections
may need up to 2-3 weeks of treatment.
Page 50 of 67
Management Infected Ulcers - Antibiotics
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And when the bone gets infected?
Lastly, treating underlying osteomyelitis is an
important therapeutic challenge. Presence of
osteomyelitis warrants long-term treatment of
at least 4 6 weeks duration with antibiotics
that penetrate well into bone such as
fluoroquinolones, clindamycin or fusidic acid.
Surgical ressection still remains the most
definitive treatment for osteomyelitis especially
for patients not responding to antibiotics.
Treating Charcots neuro-osteoarthropathy
Charcot foot refers to bone and joint destruction that occurs in the neuropathic foot
or rarely just the toe. It can be divided into three phases:
Acute onset;
Bony destruction / deformity;
Stabilistion;
1. Acute onset
Characterised by unilateral erythema and oedema and the foot is at least 2C hotter
than the contralateral foot. About 30% of patients may complain of pain or discomfort
which is rarely severe. X-ray may be normal, but a technnetium methylene
diphosphonate bone scan will detect early evidence of bony destruction.

An infected
ulcer
draining
pus
Page 51 of 67
Management The Charcot Foot
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Patients awaiting bone scan should be treated as if the diagnosis has been confirmed;
Initially the foot is off-loaded and immobilised in a non-weight-bearing cast to prevent
deformity. After 1 month, a total-contact cast is applied and the patient may mobilise
for brief period. However, the patient is given crutches and encouraged to keep
walking to a minimum.
If given early, these measures can prevent bony destruction. Bisphosphonates are
potent inhibitors of osteoclast activation and may also be used in this phase.
2. Bony destruction
Clinical signs are swelling, warmth, a temperature 2C greater than the contralateral
foot and deformities including the rocker-bottom deformity and medial convexity.
X-ray reveals fragmentation, fracture, new bone formation, subluxation & dislocation.
The aim of treatment is immobilisation until there is no X-ray evidence of continuing
bone destruction and the foot temperature is within 2C of contra lateral foot.
A photo showing a charcot foot
with an ulcer on the sole
Page 52 of 67
Management The Charcot Foot - 2
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3. Stabilisation
The foot is no longer warm and red. There may still be oedema but the difference in
skin temperature between the feet is less than 2C. the X-ray shows fracture healing,
sclerosis and bone remodelling.

The patient can now progress from a total-contact cast to an orthotic walker, fitted
with cradled moulded insoles if necessary to accommodate a rocker-bottom or medial
convexity deformity. Cautious rehabilitation should be the rule, beginning with a few
short steps in a new footwear.

Finally, the patient may progress to bespoke footwear with moulded insoles as the
rocker-bottom charcot foot with plantar bony prominence is a site of very high
pressure. Regular reduction of callus can prevent ulceration.

During the acute stage, charcot foots foot may be misdiagnosed as;
Cellulitis
Osteomyelitis
Deep vein thrombosis
Inflammatory arthropathy
Therefore a high index of suspicion is very important at this stage!
Page 53 of 67
Management The Charcot Foot - 3
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...if the foot does not stabilise or ulcer is
worsening?- Definitive management
Amputation
Referral to vascular surgeons for possible
amputation is made on clinical findings that the
ulceration is not healing/ infection worsening in spite
of intensive antibiotic therapy
Signs include:
Extensive tissue loss
Unreconstructable ischaemia
Failed revascularisation
Charcots of ankle with instability
Page 54 of 67
Management Amputation
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What about giving them some analgesia?
Treating painful diabetic neuropathy:
General approach;
Reassure the patient that intense pain improves within 2 years.
Regular appointments to monitor their pain and try new strategies if refractory to
previous attempts.
It is essential to optimise diabetic control.

Drugs;
Simple analgesics; e.g. aspirin, paracetamol, and mild opiates such as codeine
phosphate singly or in combination. Prescribe hypnotics for disturbed sleep.

Trycyclic antidepressants; e.g imipramine, amitriptyline. Commence with low dose
and gradually increase according to symptomatic response

Anticonvulsants; e.g carbamazepine, valproate, phenytoin, gabapentin, lamotrigine
may be very useful. The latter two may improve sleep in addition to pain relief.

Capsaicin is a very useful topical analgesic

Page 55 of 67
Management Pain
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So thats where we are at the moment. How about future
developments?
Prophylactic foot surgery:
The last decade has a dramatic interest in reconstructive foot surgery for
the diabetic foot. The aim of this surgery is to reduce risk of ulceration.
A short Achilles tendon may be associated with elevated forefoot plantar
pressure and hence may benefit from Achilles tendon lengthening
surgery.
Tenotomy of toe extensors may reduce toe deformities, thus preventing
recurrent ulcerations in this group of patients.
Metatarsal osteotomy may reduce the risk of ulcer recurrences in
subjects with prominent metatarsal heads.
However, currently there is no randomise control trial evidence comparing
these surgical techniques with medical therapy.
Page 56 of 67
Management New Surgical Techniques
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Well done!
You have come to the end of the last section






We suggest that you answer Question 10 to 18
to assess what you have learnt. Please
remember to write your answers on the mark
sheet before looking at the correct answers!
Page 57 of 67
End of Section 3
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Good shoe guide:
a) Toe box should be sufficiently long, broad and deep to
accommodate the toes without pressing on them, with a clear
space between the apices of the toe box

b) Shoes should be fasten with adjustable lace, strap or
velcro high on the foot in order to hold foot firmly inside
the shoe and thus reduce frictional forces when the patient
walks

c) The heel of the shoe should be over 5 cm high
to avoid weight being thrown forward into metatarsal heads

d) The inner lining of shoe should be smooth

e) Stocking or socks should not be worn with shoes
Question 10: Write T or F on the answer sheet. First complete all 5
questions, then click on the boxes and mark your answers.
a
b
c
e
d
Page 58 of 67
Section 3 Quiz
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1) .
2) .
3) .
4) .
5) .
Question 11: List five common foot problems that occur
in the population at large.Write your answer in your
mark sheet
Click here for the
answers
Page 59 of 67
Section 3 Quiz
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Question 12: Identify the following photos below. Write your
answer in your mark sheet.
Click here for
the answers
1
2
3 4
Page 60 of 67
Section 3 Quiz
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1) .
2) .
3) .
Question 13: name three cast techniques used for off-
loading pressure in neuropathic diabetic foot. Write your
answer in your mark sheet
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Page 61 of 67
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1) ..
2) ..
3) ..
4) ..
5) ..
Question 14: List five reasons why debridement is
important in the treatment of diabetic foot ulcers. Write
your answer in your mark sheet
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answers
Page 62 of 67
Section 3 Quiz
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Oral antibiotics;
1) ..
2) ..
3) ..
4) ..
Parenteral antibiotics;
1)
2)
3)
4)
Question 15: List 4 oral and 4 parenteral antibiotics used in
treating infected diabetic foot ulcers.Write your answer in your
mark sheet
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answers
Page 63 of 67
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a) .
b) .
c) .

Question 16: Describe the term charcot foot and
mention its three phases of evolution .Write your
answer in your mark sheet
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answers
Page 64 of 67
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Question 17: identify the following photos below.
Write your answer in your mark sheet
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answers
1
2
3
4
Page 65 of 67
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A.
B.
C.
D.
E.
Question 18: List 5 categories of drugs used in the
treatment of painful diabetic neuropathy. Write your
answer in your mark sheet.
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Page 66 of 67
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sources
1. A Clarke (2005). Pathology of the non-ulcerative foot. Diabetes
voice; volume 50.
2. http://www.emedicinehealth.com/diabetic_foot_care
3. Time to Act (2005). International Diabetes Federation and the
International Working Group on Diabetic Foot.
4. Edmonds ME, Foster AVM (2005). Managing the diabetic foot
(2nd edition). Blackwell Science, Oxford.
5. Khanolkar MP, Stephens JW, Bain SC. (2007) The Diabetic Foot.
(in press). Morriston Hospital, Swansea, UK.
6. www.zoobiotic.com; LarvE

data card version 2.9 and dressing
application version 2.0 (2007).
7. Levin and ONeal. Eds. John H. Bowker and Michael A. Pfeifer.
(2007) The Diabetic Foot. Mosby, Elsevier. 7
th
edition
8. The 5th International Symposium on the Diabetic Foot. (May 9-12,
2007). International Diabetes Federation. Noordwijkerhout, the
Netherlands,.

Page 67 of 67
Sources of Information/Images and References