FOOT

THE DIABETIC FOOT

 DIABETES

• -it s a disease that includes a heterogenous group

of sufferences with a different etiology but with a
common point-the hyperglycaemia associated
with disorders of the lipidic and proteic
metabolism
• -the hyperglycaemia and other secondary
changes of the other metabolisms are a
consequence of an absolute or relative failure of
the secretion of insulin
 DIABETES 2
• -it s a major problem of public health

• -complications will appear to all organs and

systems, with important modifications at the
vessels and nervous fybres
 DIABETES- EPIDEMIOLOGY
• Diabetes affects 26 million people in the
US and more than 250 million people
worldwide.
Diabetesatlas.org/American Diabetes Association 2009

• 2005: 150 mil. IN DEVELOPPED

COUNTRIES

• 2010: 285 mil.

–7 mil. NEW CASES/an
• 2025: 438 mil. !!!!!

• 2018- 823000- Romania

 14 November

World day of diabetes

 Diabetic foot

Infection, ulceration or destruction

of deep tissues OF THE FOOT associated with
neurological abnormalities
&
various degrees of peripheral vascular diseases
in the lower extremity in people with
DIABETES
• Every 30 seconds a
leg is amputated
 DIABETIC FOOT
• -the most frequent cause of hospitalisation at
the pacients with diabetes
• -every year , 4m. of diabetics will develop a
new ulcer to the foot
• -15% of the diabetics will have along their life
at least one lesion to the foot
• - pacients with diabetic foot (4%) will consume
12-15% of the resources
 DIABETIC FOOT
• -in the evolution of the diabetic foot, the
angiopathy, the neuropathy are the most
important problems and the infection will
overlap
 The Diabetic Angiopathy
• The vascular lesions-the main cause of death
• Patogenical Mechanisms- dismetabolic,
imunologic, genetic, endocrine factors
• Regarding the localisation of the lesions, the
vascular involvement is called
• -Microangiopathy
• -Macroangiopathy
 Microangiopathy 1

• Pathological changes
• -thickening of the basal membrane of the
capillary vessels
• - the lesions will appear at the legs, at the
capillaries of the subcutaneous tissue, the skin
and nerves
 Microangiopathy 2
• -Changes in the blood reologie
• - ^ the blood viscosity
• - ^ the coagulability
• - ˅ of the capacity of the RBC to deform , to
pass through the narrowed lumen
 MACROANGIOPATHY
• Atheroscerosis- big arteries and arterioles
• Particularities
• - 20 x more frequent
• -F=M
• - starts faster
• - faster evolution
• - frequent bilateral
• - on distal arteries- under the knee
Diabetic Angiopathy- Particularities
• -calcification of the media on the big and
middle arteries ( Moenckeberg disease)
• - artheriosclerosis- the thickening of the
arteriole wall and the narrowing of the
vascular lumen
• - most frequent- coronary, cerebral arteries,
the pelvic limb- stroke, myocardial infarction-
after, peripheral GANGRENE
 NEUROPATHY
• -the most frequent and precocious
complication
 The autonomous neuropathy
• Skin- ˅ sweat secretion- distal anhidrosis, dry
skin, skin tears, ulcers
• - opening of the a-v shunts- overheating of
the diabetic foot
• - opening of the a-v shunts- osteoporosis
and osteolysis
• - deformations of the foot- ulcerations,
calluses, hyperkeratosis
 The autonomous neuropathy 2
• Digestive and urogenital manifestations :
• - generalized hypotonia of the segments of the
DT
• - constipation; stones in the gallbladder
• - urinary disorders (repeated urinary infections,
urinary lithiasis
• - impotence
• Secondary cardio-vascular manifestations-
tachycardia
 Senzitive neuropathy
• “ In sock and glove”
• Symptoms ( exacerbation in the night)
• -paresthesia, precocious start
• - deaf, lingering pain , like a burn
• - cramps in the night
• - the uncertainty of going
• - anesthesia-he doesn t feel extreme
temperatures, the pain produced by lesions
• - the patient is loosing the identity of the
insensitive part
 The Motor neuropathy
• -modifications of the disposal of the fat
plantar layer
• - modifications in the ratio extensors/ flexors
• muscles
• - fingers in “hammer”, halus valgus,
hyperexcaveted foot
 The diagnosis of the complications
The diabetic foot 1
• The arteriopathy of the pelvic members :
• - anamnesis- age> 50 years, the duration of
the disease, smoking, obesity, HTA, glucose “ a
jeun “, glycosylated hemoglobin
• - clinical exam-vasculopathy and secondary
modifications
• 1. inspection- the color, trophic disorders
(skin is thin, glossy, reduced or 0 hairiness,
nagging brittle nails )
 The diagnosis of the complications
The diabetic foot 2
• 2. Palpation – low temperature, diminishing or
absent pulse
• 3. Auscultation- systolic murmur at a stenosis>
50 %, negative if stenosis is > 90 %
The Arteriopathy of the pelvic member
• paraclinic exploration :
• - cutaneous thermometry
• - time of venous filling ^ (nv-5-7)
• - claudication test
• - oscillometric
• - plethysmography
• - Doppler us
• - femoral arteriography
• - fluxomethry by MRI
 The Peripheral Neuropathy 1
• 1. Anamnesis-cutaneous hipo/hiperestesis, sensation
of hot/cold, affectation “ In sock and glove”, ^ in the
night
• 2. Clinical exam
• - Inspection-flat plantar vault/excavated, fingers in
“hammer”, Charcot foot
• - dilated veins, dry skin with calcaneal cracks,
hiperkeratosis/ulcerations in the
plantar pressure zones
• - postoperative scars
• - Palpation- good pulse beat, warm and dry skin
 The Peripheral Neuropathy 2
• Paraclinical exams:
• a. vibratory sensitivity
• b. tactile sensitivity
• c. painful sensitivity
• d. thermal sensitivity
• e. speed of the nervous driving
• f. electromyography
QUALITATIVE NEUROLOGICAL TESTS 1
QUALITATIVE NEUROLOGICAL TESTS 2
QUALITATIVE NEUROLOGICAL TESTS 3
QUALITATIVE NEUROLOGICAL TESTS 4
QUALITATIVE NEUROLOGICAL TESTS 5
 The diabetic gangrene
• - a complication of diabetes- the necrosis
localised at the foot, secondary after problems
of the blood irrigation and nervous trophicity
and also with infection
• -the wet gangrene- acute complication on a
leg with vascular problems, with severe
microangiopathy- SURGERY
 The infection of the diabetic foot
• D < - > Infection
• Infection < - > maintaining and aggravating the
metabolic imbalance
Plantar phlegmons
 THE INFECTION OF THE DIABETIC FOOT 1
• Coci gram+ aerobi:
- staphylococus aureus
- stafilococi coagulazo-negativi
- streptococi hemolitici sau non-hemolitici
- enterococi
• Bacili Gram- aerobi:
- Pseudomonas Aeruginosa
- Enterobacteriaceae (E Coli, Klebsiella, Proteus
spp)
• Germeni anaerobi:
- Clostridium perfringens
- Bacteroides spp
 THE INFECTION OF THE DIABETIC
FOOT 2
• Coci Gram + at the beginning
• Gangrene- 3-6 germs-Pseudomonas, Proteus
• Extensive gangrene- anaerobic germs
(Clostridium. Bacteroides) –gas bubbles,
crepiness at palpation, toxemia,
toxic-septic shock
Charcot foot with superinfected with
the fascia of the shank
Anatomoclinical types of infections of
the diabetic foot
• 1. Infection on an ischemic field ( affectation
of the vessels with small diameter-insufficient
irrigation, necrosis)
• -Dry gangrene- extension of the gangrene-
mummification of the whole finger, net
delimitation; selfamputation or superinfection
( wet gangrene)
• - Wet gangrene-tumefaction red-purple, local
pain, fever 38-38.5
Dry gangrene-fingers
GANGRENE fingers
 Ischemic Gangrene
( Chronical kidney disease )
Ischemie acuta
 Anatomoclinical types of infections of
the diabetic foot
- Extensive wet gangrene- surgical emergency- extended
amputation- fast extension of the septic process,
necrotic and purulent extensions along the interbones
spaces, muscles , osteoarticulary system, tendons
- Fasciitis necrosis- affectation of the fascia of the foot or
ankle- fever, shiver, modified status, punction-liquid
with a very bad smell
- Deep abcess, edema- inoculation of an inexpandable
space- strong pain, plantar tummefaction- septic
thrombosis-extended wet gangrene
EXTENSIVE WET GANGRENE
EXTENSIVE WET GANGRENE WITH FASCEITIS
AND MYOSITIS OF THE LEG
 ANATOMOCLINICAL TYPES OF
INFECTIONS OF THE DIABETIC FOOT
• -Necrotic cellulite- infection of the
subcutaneous fat tissue- cutaneous gangrene-
thrombosis of the local vessels- frequent
supuration
• - The phlegmon of the dorsal part oh the foot-
• Painful tummefaction hyperemia,
expansion- evolution to cellulitis or extensive
fasceitis of the leg, cutaneous gangrene
SUPPURATION OF THE DORSAL PART
Anatomoclinical types of infections of
the diabetic foot
• Infections at a pacient with neuropatic terrain
• - will appear posttraumatic lesions,
ulcerations with silent evolution, no pain
• The neuropathic ulcer- one or multiple,
one side/ bilateral, frequent on the planta,
warm foot with normally coloured skin/
hiperemia, dry ,
ULCERE NEUROPATE PLANTARE
PICIOR CHARCOT- OSTEOARTRITA FISTULIZATA
OSTEITA/ OSTEOARTRITA
 Treatment –General principles
• Prophilaxis- medical education
• The treatment of the risk factors :
• - The chronic obstructive arteriopathy-
vasodilators, anticoagulants, antiplatelets.
Vascular surgery or open surgery (
endarterectomy, by-passes )
• - The diabetic neuropathy- neurolisis of the tibial
posterior nerve, tricyclic antidepressants,
antiarrhythmic, anticonvulsant
• -Biomechanical disorders- the reduction of the
pressure on the modified areas
 Curative Treatment
• -antibiotherapy (antibiogram )
• - surgical- cleaning of the septic process,
evacuation of the puss, remove of the
gangrenous and suppurated tissue ( INCISION,
EVACUATION, DEBRIDEMENT)
• -AMPUTATION-PARTIAL
• -MAJOR-thigh or shank (extended
gangrene, fasceiitis, celulitis with anaerobic
germs )
•