Diabetic foot.ppt

(1)

(2)

Background

• Diabetic foot problems are the

most common cause of non-traumatic limb amputation

(3)

Pathophsiology of Foot Ulceration



Neuropathic



Ischemic

(4)

Diabetic Neuropathy



Sensorimotor & peripheral sympathatic

neuropathy are major risk factors for

ulcer



History & careful foot

examination

are

mandatory to diagnose neuropathy



Up to 50% of type2 diabetic patient have

significant neuropathy & at risk of foot

(5)

Peripheral vascular disease (PVD)

& diabetes

 PVD is the most important factor related to

outcome of diabetic foot ulcer

 PVD is diagnosed by simple clinical examination

 Non invasive vascular test determines probability

of healing

 Symptoms of ischemia may be masked by

neuropathy

 Microangiopathy shouldn't be accepted as

primary cause of ulceration

 Outcome of revascularization is similar to that in

(6)

Diabetic Foot Infection



Infection in diabetic foot is limb

threatening



Signs of infection may be absent in

diabetic pt. with foot ulcer



Superficial infection is usually caused by

gram +ve cocci, deep infection is poly

microbial



Surgical debridement is essential in acute

(7)

(8)

Biomechanics of foot wear

(9)

(10)

(11)

Staging of Diabetic Foot

Stage

Clinical condition

1 Normal

2 High risk

3 Ulcerated

4 Cellulitic

5 Necrotic

6 Major

(12)

Risk Factors

 Glycaemic control-DCCT

  with age: 5% 20-29 years, 44.2% 70-79 years  > 50% T2DM >60 years of age

  with duration of diabetes: 20.8% < 5years, 36.8%>10

years

  Smoking

  Microalbuminuria  Height

(13)

Classification of Diabetic Neuropathy



Symmetric polyneuropathy



Autonomic neuropathy



Polyradiculopathy

(14)

Symmetric Polyneuropathy



Most common form of diabetic

neuropathy



Affects distal lower extremities and

hands (“stocking-glove” sensory loss)



Symptoms/Signs



Pain



Paresthesia/dysesthesia

(15)

Complications of Polyneuropathy



Ulcers



Charcot arthropathy



Dislocation and stress fractures



Amputation - Risk factors include:

 Peripheral neuropathy with loss of protective sensation  Altered biomechanics (with neuropathy)

 Evidence of increased pressure (callus)  Peripheral vascular disease

(16)

Presentations

Diffuse symmetrical

sensorimotor polyneuropathy



Predominantly sensory



Predominantly feet





pain and temperature sensation



Parasthesiae and numbness



Neurogenic pain/allodynia



Neuropathic oedema

(17)

Autonomic neuropathy



Affects the autonomic nerves controlling

internal organs



Peripheral



Genitourinary



Gastrointestinal



Cardiovascular



Is classified as clinical or subclinical

(18)

(19)

Mononeuropathies

Acute ? Secondary to ischaemia



Pain and weakness (severe)



Resolve over months



Amyotrophy (Older > )

♂ ♀



3

rd

nerve



6

th

nerve

(20)

(21)

Neuro-osteoarthropathy(Charcot

foot)



Non- infective pathology



Should be suspected in any

swollen

hot

erythematous foot



Differentiation from infection is

important to prevent misdiagnosis &

possible amputation



Treatment should aim at preventing

(22)

(23)

Diagnosis of potential foot problems

Annual review

 Enquire annually for:

· Painful neuropathy · Loss of sensation · Erectile impotence

 Note duration of DM, treatment,

complications & weight

 Ask about other manifestations of

autonomic neuropathy if:

· Other complications are present · Anaesthesia is contemplated

(24)

Assessment

of Diabetic Foot



Neuropathy



Ischemia



Deformity



Callus



Swelling



Skin breakdown

(25)

Diagnosis

Examine:

 For evidence of peripheral

neuropathy annually

 Monofilament (10gm, 6 places)

 OR if new symptoms

 Vibration

 Monofilament (10gm, 6 places)  ?Pain

 For postural hypotension if

(26)

Differential Diagnosis

Consider differential diagnoses

 Hereditary - HSMN  Ethanol

 B12/folate  Malignancy  Renal failure  Drugs

 AI disease

(27)

How To Prevent Foot Problems

5 corner stones



Regular inspection & examination of

foot & foot wear



Identification of high risk patient



Education of patient, family & health

care providers



Appropriate foot wear

(28)

Prevention

Diabetes Control

 DCCT (1995)

 Tight control-3% neuropathy at 5 years  Conventional-10% neuropathy

 UKPDS (1998)

 Tight control (HbA1c 7%)-31.2% neuropathy at 15 years  Conventional (HbA1c 7.9%)-51.7%

 P=0.005

(29)

Essentials of Foot Care

 Examination

 Annually for all patients

 Patients with neuropathy - visual inspection of feet at

every visit with a health care professional

 Advise patients to:

 Use lotion to prevent dryness and cracking  File calluses with a pumice stone

 Cut toenails weekly or as needed

 Always wear socks and well-fitting shoes

 Notify their health care provider immediately if any foot

(30)

Assessment and awareness



Regular assessment of feet is

important to check for:



Sense of feeling and pulses in

the feet



Foot problems/deformities or

past history of foot ulcer



If foot problems are present

(31)

Assessment and awareness



Always be aware of

High Risk Feet

 Loss of feeling  Poor blood supply

(32)

Caring for the feet



Check feet every day.



Individuals may have serious

foot problems, but feel no

pain.



Check feet for cuts, sores,

red spots, swelling, and

infected toenails.



Make checking feet part of

(33)

Caring for the feet



Wash feet every day



Wash feet in warm, not

hot, water. Do not soak

because skin will get dry.



Dry feet well. Be sure to

(34)

Caring for the feet



Keep the skin soft and

smooth



Rub a thin coat of skin

lotion or cream.



Do not put lotion or

(35)

Caring for the feet



Smooth corns and calluses

gently.

 Check with the doctor/podiatrist before

using a pumice stone.

 Use pumice stone after bathing or

showering

 Don’t cut corns and calluses.

 Don't use razor blades, corn plasters, or

(36)

Caring for the feet



Toenails should be trimmed

regularly

 With clippers after bath/shower.  Straight across and smooth with

an emery board or nail file.

 don't cut into the corners of the

toenail.

 If toenails are thick or yellowed,

(37)

Preventing foot problems



Protect the feet



Wear shoes and socks at all times.



Choose clean, lightly padded socks

that fit well. Socks that have no seams

are best.



Check the insides of shoes

before putting them on to be

sure the lining is smooth and

(38)



Protect the feet



Wear shoes that fit well and

protect the feet.



Athletic or walking shoes are

good for daily wear. They

support the feet and allow

them to "breathe."



Avoid vinyl or plastic shoes,

(39)



Appropriate shoes



Pointed toes or high

heels put too much

pressure on the toes.



Shoes also need to be

(40)



Protect your feet from

hot and cold.

 Keep your feet away from

radiators and open fires.

 Do not use hot water bottles on

feet.

 Lined boots are good in winter to

keep your feet warm and socks at night

 Remember to use sunscreen on

(41)

Preventing foot problems



Keep the blood flowing to the feet.

 Keep feet up when sitting.  Exercises for the feet

 Wiggle toes for 5 minutes, 2 or 3 times a day

 Move ankles up and down and in and out.

 Don’t

 Cross legs

 Wear tight socks, elastic or rubber bands, or garters around

your legs.

 Don't smoke

 Smoking reduces blood flow to feet.

 Control

(42)

Treatment-Painful neuropathy

_{General Measures}

_{Improve glycaemic control}

_{Exclude or treat other contributory factors}

•_{Alcohol excess}

•_{Vitamin B12 deficiency/Folate} •_Uraemia

_{Simple analgesia-NSAID/Paracetamol} _{Explanation, empathy and reassurance}

_{Choose drugs according to dominant symptoms}



Burning pain

_Tricyclics _{Anticonvulsants} _Duloxetine 

Lancinating

pain

_Tricyclics _{Anticonvulsants} _Duloxetine

_{Other symptoms} _Allodynia

•_{Plastic film} •_{Leg cradle at night}

_{Restless legs}

•_Ropinirole

_{Painful Cramps}

(43)

NICE Clinical Guideline 173 (2014) Treatment of all neuropathic pain

 Offer a choice of amitriptyline, duloxetine, gabapentin or pregabalin as

initial treatment for neuropathic pain (except trigeminal neuralgia).

 _{If the initial treatment is not effective or is not tolerated, offer one of the}

remaining 3 drugs, and consider switching again if the second and third drugs tried are also not effective or not tolerated.

 _{Consider tramadol only if acute rescue therapy is needed.}

 Consider capsaicin cream for people with localised neuropathic pain who