Diabetic foot

Dr. Araz Shexani

 objectives
definition
Epidemiology
Pathophysiology
Classification
Prevention
management
 Definition
The complications of longstanding diabetes mellitus
which often appear in the foot and, causing chronic
disability.
 Epidemiology

More than 30% of patient attending diabetic

clinics have evidence of peripheral neuropathy or
vascular disease
about 40% of non-trauma related amputations are
for complications of diabetes.
nearly one in six patients die within one year of their
infection
 Pathophysiology

Factors predisposing diabetic patients to

developing :diabetic foot are
Peripheral vascular disease.1
damage to the peripheral nerves.2
,Reduced resistance to infection.3
Osteoporosis .4
 Peripheral vascular disease
atheroseclerosis affects mainly the medium sized
vessels below the knee
The pt. may complain of claudication or ischemic
changes and ulceration in the foot.
The skin feels smooth and cold the nails show trophic
changes .
pulses are weak or absent
Superficial ulceration occurs on the toes
deep ulceration typically under the heel these ulcers
are painful and tender
Digital vessels occlusion may cause dry gangrene of
one or more toes.
 proximal vascular occlusion resulting in extensive wet
gangrene.
 :Peripheral neuropathy
early on the pt usually unaware of the abnormality but
clinical tests will discover
loss of vibration and position sense and
diminish of temperature
Diminish of discrimination in the feet
Symptoms : mainly due to
sensory impairment:
 symmetrical numbness and parasthesia,
 dryness and blistering of the skin,
 superficial burns and skin ulcers due to shoe scuffing or

localized pressure
Motor loss:
muscle weakness and intrinsic muscle imbalance
usually manifests as claw toes with high arches and
.this may in turn predispose to plantar ulceration
 Infections
diabetes, if not controlled is known to have
adverse effect on the white cell function.
This combined with the
local ischemia,
insensitivity to skin injury and
localized pressure due to deformity,
makes sepsis an ever recurring hazard.
 Classification
:Diabetic foot infection may be classified as

superficial: often associated with ulceration.

Deep infection: may involve

soft tissues only with abscess formation or
can involve bones (osteitis or osteomylitis). This type of
infection can also involve local joints (pyogenic
arithritis).
Wagner classification system
most widely used and universally accepted grading
systems for DFU
used to assess ulcer depth
0 Pre-ulcerative area without open lesion
1 Superficial ulcer (partial/full thickness)
2 Ulcer deep to tendon, capsule, bone
3 Stage 2 with abscess, osteomyelitis or joint sepsis
4 Localized gangrene
5 Global foot gangrene.
:Prevention
insist on regular attendance at a diabetic clinic.
full compliance with medication
examination for early signs of vascular or neurological
abnormality.
advice on foot care and footwear and a high level of
skin hygiene.
Foot care for the at risk
patients
:To do list
Inspect the foot daily using a mirror to see the sole and *
. don’t forget between the fingers
Wash feet daily*
Apply lotion to avoid skin cracks and if present skin *
cracks should be kept clean and covered
Use a comfortable shoe wear and change it often*
Inspect shoes before wearing it from inside and*
outside. *Great care is needed with nail trimming
:Not to do list
Smoking *
Step into bath tub without checking the temperature of *
. the water
.use hot water bottles or heating pad*
use keratolytic agent to treat the calluses or corn.*
.*Wearing a tight shoes or stocking
walking with barefeet*
Management of diabetic foot
For the management of diabetic foot there should be a
multidisciplinary team comprising
a physician (or endocrinologist) ,
orthopaedic surgeon,
General surgeon,
chiropodist and orthotist
Evaluation of diabetic foot patient
:Peripheral neuropathy
Sensory: Examination for early signs of neuropathy
should include the use of
Semmes-Weinstein hairs (for testing skin sensibility)
Biothesiometer (for testing vibration sense),
Thermal discrimination test,
And joint position sense.
Motor: examine for wasting, weakness, absent or
diminished tendon reflex, and deformities (claw toes,
hammer toes, pes cavus). This can be enhanced by the
EMG & N/C study.
Peripheral vascular damage: examine for
the pulses,
skin temperature,
trophic changes in the skin and nails
Peripheral vascular examination is enhanced by using
Doppler ultrasound probe,
ankle brachial index measurement,
Absolute toe pressure,
transcutaneous oxygen measurement,
angiography.
:Infection
 the local and systemic signs of infection.
 Ulcers must be swabbed for infecting organisms.
 Magnetic resonance imaging (MRI) is the most specific
and sensitive non-invasive test to evaluate
 Osteomyelitis
 probable abscess
 sinus tract formation.
 Bone scans, such as the white blood cell labeled Indium-111,
Technetium-99m HMPAO and Sulfur Colloid Marrow Scan,
 distinguishing acute and chronic infections,
 identifying OM from Charcot neuroarthropathy
Osteopathy:
Examine for Charcot deformities
flatening of the foot arches,
rocker-bottom deformity,
prominent metatarsl heads.
X-ray examination may reveal
periosteal reactions,
osteoporosis,
cortical defects near the articular margins and
osteolysis - often collectively described as 'diabetic
osteopathy
Laboratory investigations :
WBC elevated in 50% of patients.
renal function,
electrolytes,
acidosis,
blood glucose level.
Hemoglobin A1C levels provide a barometer of glycemic control
averaged over the previous 2-3 months.
Acute phase reactants ESR &CRP (baseline and post-
treatment CRP, ESR and WBC were significantly elevated in
patients who ultimately required amputation).
Total serum protein and albumin→nutritional status.
treatment
:According to wagner classification
Grade 0 (skin intact): calluses should be trimmed so as
not mask active ulcer, advise the patient how to do daily
foot care and apply the preventive measures.(extra depth
shoes and pressure relieving insole)
 Grade 1&2(superficial & deep ulcer but without infection ):
the aim here is to heal the skin, after desloughing the
ulcer and removing the hyper keratotic skin the ulcer can
be dressed locally, the application of a skin - tight
POP(total contact cast) changed weekly will allow most of
the ulcers to heal. It also allows the patient to be mobile
Grad 3 (grade2 with infection):
deep infection without abscess formation can be treated
by strict rest, elevation, soft tissue support and AB.
Occasionally, septicemia calls for admission to
hospital and treatment with intravenous antibiotics.
Any form of abscess formation needs to be drained
urgently and the deeper tissues thoroughly debrided.
Deep ulcers in certain sites are more problematic than
elsewhere . Once an ulcer is healed the use of
appropriate insoles and shoes can prevent further
ulceration.
Grade 4(localized gangrene):
Ischaemic changes need the attention of a vascular surgeon
who can advise on ways of improving the local blood supply.
Arteriography may show that bypass surgery is feasible.
Dry gangrene of the toe can be allowed to demarcate before
local amputation.
With diabetic gangrene septic arithritis is not uncommon ,
the entire ray(toe+metatarsal bone ) should be amputated.
In More extensive gangrene partial foot amputation done
e.g. through the midtarsal joints(Chopart),thruogh
tarsometatarsal joints(lisfranc), thruogh metatarsal bone,
syme’s amputation
Grade 5(Global foot gangrene) :
severe occlusive disease with wet gangrene may call for
immediate amputation.
This should be undertaken at a level where there is a
realistic chance of the wound healing.
Treatment of special problems
Ischaemic changes : need the attention of a vascular
surgeon who can advise on ways of improving the local
blood supply. Arteriography may show that bypass
surgery is feasible.
Insufficiency fractures: should be treated, if
possible, without immobilizing the limb; or, if a cast is
essential, it should be retained for the shortest
possible period.
Fixed foot deformities : corrective surgery should be
considered.
Neuropathic joint disease : is a major challenge.
Arthrodesis is fraught with difficulty,
 very poor union rate,
 sometimes is simply not feasible.

'Containment' of the problem in a weight-relieving

orthosis may be the best option.
 Home message
Diabetic foot is the complications of longstanding
diabetes mellitus.
 common problem and can lead to serious
consequences.
Four major predisposing factors: ischemia,
neuropathy, immunopathy and osteopathy.
insist on regular attendance at a diabetic clinic and
apply preventive measures.
multidisciplinary team is required for the
management of diabetic foot.