Download MBBS (Bachelor of Medicine, Bachelor of Surgery) 1st Year, 2nd Year, 3rd Year and Final year Surgery 17 Diabetic Foot PPT-Powerpoint Presentations and lecture notes
Diabetic Foot
Objectives
? Define diabetic foot
? Explain etiopathogenesis of diabetic foot ulcer
? Wagner grades
? Understand Charcot's foot
? Explain prevention strategies to patient
Definition
A foot with a constellation of pathologic changes
affecting the lower extremity in diabetics, often
leading to amputation and/or death due to
complications; the common initial lesion leading to
amputation is a nonhealing skin ulcer, induced by
regional pressure, pathogenically linked to sensory
neuropathy, ischemia, infection
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Extent
? 20 million DM patients in India ( 2 Crore)
? DM largest cause of neuropathy
? Half don't know
? Foot ulcerations is most common cause of hospital
admissions for Diabetics
? Expensive to treat, may lead to amputation and need for
chronic institutionalized care
? After amputation 30% lose other limb in 3 years
? After amputation 2/3rds die in five years
? Type II can be worse
? 15% of diabetic will develop a foot ulcer
Pathophysiology
? Vascular disease
? Neuropathy
? Sensory
? Motor
? Autonomic
Neuropathy
? Changes in the vasonervosum with resulting
ischemia ? cause
? Increased sorbitol in feeding vessels block flow
and causes nerve ischemia
? Intraneural accumulation of advanced
products of glycosylation
Abnormalities of all three neurologic systems
contribute to ulceration
Vascular Disease
? 30 times more prevalent in diabetics
? Diabetics get arthrosclerosis obliterans or "lead
pipe arteries"
? Calcification of the tunica media
? Endothelial changes
? Often increased blood flow with lack of elastic
properties of the arterioles
? Not considered to be a primary cause of foot
ulcers
Autonomic Neuropathy
? Regulates sweating and perfusion to the limb
? Loss of autonomic control inhibits
thermoregulatory function and sweating
? Result is dry, scaly and stiff skin that is prone to
cracking and allows a portal of entry for bacteria
Autonomic Neuropathy
Motor Neuropathy
? Mostly affects forefoot ulceration
? Intrinsic muscle wasting ? claw toes
? Equinus contracture
Sensory Neuropathy
? Loss of protective sensation
? Starts distally and migrates proximally in
"stocking" distribution
? Large fibre loss ? light touch and proprioception
? Small fibre loss ? pain and temperature
? Usually a combination of the two
Sensory Neuropathy
? Two mechanisms of Ulceration
? Unacceptable stress few times
? rock in shoe, glass, burn
? Acceptable or moderate stress repeatedly
? Improper shoe s
? deformity
Patient Evaluation
? Medical
? Vascular
? Orthopedic
? Identification of "Foot at Risk"
Patient Evaluation
Semmes-Weinstein Monofilament Aesthesiometer
? 5.07 (10g) seems to be threshold
? 90% of ulcer patients can't feel it
? Only helpful as a screening tool
Patient Evaluation
? Medical
? Optimized glucose control
? Decreases by 50% chance of foot problems
Patient Evaluation
? Vascular
? Assessment of peripheral pulses of paramount
importance
? If any concern, vascular assessment
D
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? ABI (n>0.45)
U
CM
? Sclerotic vessels
? Toe pressures (n>40-50mmHg)
? TcO2 >30 mmHg
? Expensive but helpful in amp. level
Patient Evaluation
? Orthopedic
? Ulceration
? Deformity and prominences
? Contractures
D
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Patient Evaluation
? X-ray
? Lead pipe arteries
? Bony destruction (Charcot or osteomyelitis)
D
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Patient Evaluation
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Patient Evaluation
? Nuclear medicine
? Overused
? Combination Bone scan and Indium scan can
be helpful in questionable cases (i.e. Normal X-
rays)
D
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? Gallium scan useless in these patients
U
CM
? Best screen ? indium ? and if Positive ? bone
scan to differentiate between bone and soft
tissue infection
Patient Evaluation
? CT can be helpful in visualizing bony anatomy for
abscess, extent of disease
? MRI has a role instead of nuclear medicine scans
in uncertain cases of osteomyelitis
D
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Ulcer Classification
Wagner's Classification
0 ? Intact skin (impending ulcer)
1 ? superficial
2 ? deep to tendon bone or ligament
3 - osteomyelitis
D
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4 ? gangrene of toes or forefoot
5 ? gangrene of entire foot
Classification
Type 2 or 3
D
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Classification
Type 4
D
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Treatment
? Patient education
? Ambulation
? Shoe ware
? Skin and nail care
D
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? Avoiding injury
U
CM
? Hot water
? F.B's
Six intervention demonstrate efficacy in
diabetic foot management
1- off loading
2- Debridement and drainage
3- wound dressing
4- appropriate use of antibiotic
5- revascularization
6- limited amputation
Treatment
? Wagner 0-2
? Total contact cast
? Distributes pressure and allows patients to continue
ambulation
? Principles of application
? Changes, Padding, removal
? Antibiotics if infected
Treatment
Treatment
? Wagner 0-2
? Surgical if deformity present that will
reulcerate
? Correct deformity
? exostectomy
Treatment
? Wagner 3
? Excision of infected bone
? Wound allowed to granulate
? Grafting (skin or bone) not generally effective
Treatment
? Wagner 4-5
? Amputation
? ? level
? 5 P's
? 3D's
Treatment
? After ulcer healed
? Orthopedic shoes with accommodative
(custom made insert)
? Education to prevent recurrence
Charcot Foot
? More dramatic ? less common 1%
? Severe non-infective bony collapse with
secondary ulceration
? Two theories
? Neurotraumatic
? Neurovascular
Charcot Foot
? Neurotraumatic
? Decreased sensation + repetitive trauma =
joint and bone collapse
? Neurovascular
? Increased blood flow increased osteoclast
activity osteopenia Bony collapse
? Glycolization of ligaments brittle and fail
Joint collapse
Classification
? Eichenholtz
? 1 ? acute inflammatory process
? Often mistaken for infection
? 2 ? coalescing phase
? 3 - consolidation
Indications for Amputation
? Uncontrollable infection or sepsis
? Inability to obtain a plantar grade, dry foot that
can tolerate weight bearing
? Non-ambulatory patient
? Decision not always straightforward
Conclusion
? Multi-disciplinary approach needed
? Going to be an increasing problem
? High morbidity and cost
? Solution is probably in prevention
? Most feet can be spared...at least for a while
Prevention
? Diabetic control
? Foot care
Diabetic foot successfully treated !!
This post was last modified on 08 April 2022