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Ajdabya University – Medical College
General Surgery Department
Dr. Abdulgadir Almograby , MD
Diabetic foot overview
)Revision(
Objectives
1-Definition of diabetic foot
2-Epidemiology & significance of the problem
3-Pathophysiology of diabetic foot
4-Risk factors of diabetic foot
5-Clinical features of diabetic foot
6-Management of diabetic foot
7-Prevention of diabetic foot complications
(4Dos and 4 Don't(
Definition
1-Definition of diabetic foot
Diabetic foot is a spectrum of foot disorders
occurring in diabetics ranging from foot
ulceration to gangrene as a result of ischemia ,
neuropathy or both and -/+ an infection [1[
DF= is the foot of diabetic patient
Diabetic foot:
Infection
Ulceration
Charcot’s foot
Gangrene
Ischemia
Neuropathy
Neuro-ischemia
Infection/Sepsis
Definition
Occurring
in Diabetic
patients
Epidemiology
Rule of 15% *:
15%of people with diabetes develop ulcers
15%of ulcers develop osteomyelitis
15%of ulcers result in amputation
*Armstrong, David G. and Lavery, Lawrence A. (2005(.
Clinical Care of the Diabetic Foot. American Diabetes Association. ISBN-10:
1580402232
Cost of diabetic foot
20%of All hospital admissions of diabetic
patients are due to foot problems
]1[Average hospital stay = 16 weeks.
Length of hospital stay for people with diabetic foot
problems is 13 days longer than for people with
diabetes who do not have foot problems, after
adjusting for age, sex, ethnicity, deprivation, elective or
emergency admission, and surgical or non-surgical
*specialty. *Foot care for people with diabetes in the NHS
in England: The economic case for change
March 2012
Cost of diabetic foot
USA
14I IDF Diabetes Atlas I Sixth edition
Ischemia Neuropathy Infection
Etiology of DF
Diabetic
Sensory
Neuropathy
NO pain
sensation
Foot > Vulnerable
to Repetitive
Unnoticed
Trauma
Ulceration
7Folds
Risk
Neuropathic vs. Ischemic DFUs
Variable %35Neuropathic ulcer %15Ischemic ulcer
1-Pain
2-Pulse
3-Sensation
4-Local Temp
5-Site
6-Claudication
7-Treatment
Painless
Normal arterial pulses
Loss of sensation
Warm foot
Plantar ulceration
No intermittent claudication
Treated by local measures
Painful
Reduced or absent pulses
Variable sensory findings
May be cold foot
Toe ulceration
Intermittent claudication
Requires reconstructive
)+/-Revascularization )
surgery
]1[
PERIPHERAL NEUROPATHY
Neuropathy Features
Sensory Neuropathy Loss of protective sensations
More vulnerable to physical,
chemical and thermal trauma
Motor Neuropathy Foot deformities (such as
hammer toes and claw foot), which
may result in abnormal
pressures over bony prominences
Autonomic Neuropathy
Fissures, cracking and callus dry
skin,
Bounding dorsal pulses.
]7[Boulton AJ, Armstrong DG, Albert SF, et al. Comprehensive foot examination
and risk assessment. Diabetes Care 2008; 31: 1679-85.
Diabetic Sensory
Neuropathy
Loss of protective sensation is a major
component of nearly all DFUs . [4,5].
It is associated with a seven–fold increase in risk
of ulceration.
Patients with a loss of sensation will have
decreased awareness of pain and other
symptoms of ulceration and infection. [6]
Diabetic Sensory
Neuropathy
A-“Glove and Stocking” distribution
B- Paresthesia
C- Anesthesia
TESTING FOR LOSS OF SENSATION:
Two simple and effective tests for peripheral
neuropathy are commonly used:
1-10g (Semmes-Weinstein) monofilament
*2-Standard 128Hz tuning fork.
Diabetic Sensory
Neuropathy Examination
Using a monofilament to test for neuropathy *BEST PRACTICE GUIDELINES: WOUND
MANAGEMENT IN
DIABETIC FOOT ULCERS
Diabetic Motor
Neuropathy
Diabetic Autonomic
Neuropathy
Loss of Sympathetic tone = VD
Diabetic foot Ischemia
DIABETIC FOOT DISORDERS VOLUME 45, NUMBER 5, SEPTEMBER/OCTOBER 2006 S–5
Diabetic foot Ischemia features
Asymptomatic
Intermittent claudications
Impotence
Symptoms & signs of ischemia:
Pain , coldness ,pallor, Rest pain , Absent
pulsations
Ulceration[painful ], Sepsis [Fung-Bact.] –
Gangrene. : tissue destruction ]1[
Diabetic foot infection features
Fever, chills ,rigors , tachycardia, swelling,
discharge , loss or decr. Function ,less pain
Inter-digital(web) fungal infection (maceration(
Bacterial infection =( cellulitis –localized or
spreading ) , tissue necrosis , Abscess ,
Osteomyelitis , +/_ Gangrene . [1]
Diabetic foot infection features
Bacteriology =Polymicrobial
DIABETIC FOOT DISORDERS VOLUME 45, NUMBER 5, SEPTEMBER/OCTOBER 2006 S–31
Non-invasive
1-Blood glucose, HbA1c
2-RFT,Lipid profile
3-ABI, Segmental pressure,
Digital pressure
NB-[ ABI may be falsely
Elevated due to medial
sclerosis].
4-X-rays of foot
Invasive
Angiography:
Conventional , CTA , MRA.
Investigations of DF
]1[
Management of Diabetic foot
Neuropathic Diabetic foot
1-Control infection:
Antibiotics against Both
Areobes & Anaerobes
2-Drain & Debride:
Wide local excision of
necrotic tissues
Ischemic Diabetic foot
1-Formal assessment Of
the vascular tree
with Angiography
2-Revascularization of the
foot [By Angioplasty or
bypass surgery]
3-After restoration of
blood supply = treat as
neuropathic disease.
]1[
Classification systems for DFUs
Wagner Classification System
Prevention
The old adage that:
)prevention is better than cure(
is better illustrated in the management of the
diabetic foot than anywhere else in
medicine[1[.
Prevention
4Dos 4Don't
Do
1-Carefully wash and dry feet daily
2-Inspect feet for injury daily
3-Take meticulous care of toenails
4-Apply antifungal powder to feet
daily
Don't
1-Walk barefoot
2-Wear ill-fitting shoes
3-Use a hot-water
bottle
4-Ignore any foot injury
[1[
Together To Make - Almgareaf
Ajdabia Hospital as Teaching
Hospital = Campaign

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Diabetic foot lecture - 4rth year Medical Students 2017(Revision )

  • 1. Ajdabya University – Medical College General Surgery Department Dr. Abdulgadir Almograby , MD Diabetic foot overview )Revision(
  • 2. Objectives 1-Definition of diabetic foot 2-Epidemiology & significance of the problem 3-Pathophysiology of diabetic foot 4-Risk factors of diabetic foot 5-Clinical features of diabetic foot 6-Management of diabetic foot 7-Prevention of diabetic foot complications (4Dos and 4 Don't(
  • 3. Definition 1-Definition of diabetic foot Diabetic foot is a spectrum of foot disorders occurring in diabetics ranging from foot ulceration to gangrene as a result of ischemia , neuropathy or both and -/+ an infection [1[ DF= is the foot of diabetic patient
  • 5. Epidemiology Rule of 15% *: 15%of people with diabetes develop ulcers 15%of ulcers develop osteomyelitis 15%of ulcers result in amputation *Armstrong, David G. and Lavery, Lawrence A. (2005(. Clinical Care of the Diabetic Foot. American Diabetes Association. ISBN-10: 1580402232
  • 6. Cost of diabetic foot 20%of All hospital admissions of diabetic patients are due to foot problems ]1[Average hospital stay = 16 weeks. Length of hospital stay for people with diabetic foot problems is 13 days longer than for people with diabetes who do not have foot problems, after adjusting for age, sex, ethnicity, deprivation, elective or emergency admission, and surgical or non-surgical *specialty. *Foot care for people with diabetes in the NHS in England: The economic case for change March 2012
  • 7. Cost of diabetic foot USA 14I IDF Diabetes Atlas I Sixth edition
  • 8. Ischemia Neuropathy Infection Etiology of DF Diabetic Sensory Neuropathy NO pain sensation Foot > Vulnerable to Repetitive Unnoticed Trauma Ulceration 7Folds Risk
  • 9. Neuropathic vs. Ischemic DFUs Variable %35Neuropathic ulcer %15Ischemic ulcer 1-Pain 2-Pulse 3-Sensation 4-Local Temp 5-Site 6-Claudication 7-Treatment Painless Normal arterial pulses Loss of sensation Warm foot Plantar ulceration No intermittent claudication Treated by local measures Painful Reduced or absent pulses Variable sensory findings May be cold foot Toe ulceration Intermittent claudication Requires reconstructive )+/-Revascularization ) surgery ]1[
  • 10. PERIPHERAL NEUROPATHY Neuropathy Features Sensory Neuropathy Loss of protective sensations More vulnerable to physical, chemical and thermal trauma Motor Neuropathy Foot deformities (such as hammer toes and claw foot), which may result in abnormal pressures over bony prominences Autonomic Neuropathy Fissures, cracking and callus dry skin, Bounding dorsal pulses. ]7[Boulton AJ, Armstrong DG, Albert SF, et al. Comprehensive foot examination and risk assessment. Diabetes Care 2008; 31: 1679-85.
  • 11. Diabetic Sensory Neuropathy Loss of protective sensation is a major component of nearly all DFUs . [4,5]. It is associated with a seven–fold increase in risk of ulceration. Patients with a loss of sensation will have decreased awareness of pain and other symptoms of ulceration and infection. [6]
  • 12. Diabetic Sensory Neuropathy A-“Glove and Stocking” distribution B- Paresthesia C- Anesthesia
  • 13. TESTING FOR LOSS OF SENSATION: Two simple and effective tests for peripheral neuropathy are commonly used: 1-10g (Semmes-Weinstein) monofilament *2-Standard 128Hz tuning fork. Diabetic Sensory Neuropathy Examination Using a monofilament to test for neuropathy *BEST PRACTICE GUIDELINES: WOUND MANAGEMENT IN DIABETIC FOOT ULCERS
  • 15. Diabetic Autonomic Neuropathy Loss of Sympathetic tone = VD
  • 16. Diabetic foot Ischemia DIABETIC FOOT DISORDERS VOLUME 45, NUMBER 5, SEPTEMBER/OCTOBER 2006 S–5
  • 17. Diabetic foot Ischemia features Asymptomatic Intermittent claudications Impotence Symptoms & signs of ischemia: Pain , coldness ,pallor, Rest pain , Absent pulsations Ulceration[painful ], Sepsis [Fung-Bact.] – Gangrene. : tissue destruction ]1[
  • 18. Diabetic foot infection features Fever, chills ,rigors , tachycardia, swelling, discharge , loss or decr. Function ,less pain Inter-digital(web) fungal infection (maceration( Bacterial infection =( cellulitis –localized or spreading ) , tissue necrosis , Abscess , Osteomyelitis , +/_ Gangrene . [1]
  • 20. Bacteriology =Polymicrobial DIABETIC FOOT DISORDERS VOLUME 45, NUMBER 5, SEPTEMBER/OCTOBER 2006 S–31
  • 21. Non-invasive 1-Blood glucose, HbA1c 2-RFT,Lipid profile 3-ABI, Segmental pressure, Digital pressure NB-[ ABI may be falsely Elevated due to medial sclerosis]. 4-X-rays of foot Invasive Angiography: Conventional , CTA , MRA. Investigations of DF ]1[
  • 22. Management of Diabetic foot Neuropathic Diabetic foot 1-Control infection: Antibiotics against Both Areobes & Anaerobes 2-Drain & Debride: Wide local excision of necrotic tissues Ischemic Diabetic foot 1-Formal assessment Of the vascular tree with Angiography 2-Revascularization of the foot [By Angioplasty or bypass surgery] 3-After restoration of blood supply = treat as neuropathic disease. ]1[
  • 23. Classification systems for DFUs Wagner Classification System
  • 24. Prevention The old adage that: )prevention is better than cure( is better illustrated in the management of the diabetic foot than anywhere else in medicine[1[.
  • 25. Prevention 4Dos 4Don't Do 1-Carefully wash and dry feet daily 2-Inspect feet for injury daily 3-Take meticulous care of toenails 4-Apply antifungal powder to feet daily Don't 1-Walk barefoot 2-Wear ill-fitting shoes 3-Use a hot-water bottle 4-Ignore any foot injury [1[
  • 26. Together To Make - Almgareaf Ajdabia Hospital as Teaching Hospital = Campaign

Notes de l'éditeur

  1. Classification of Diabetic foot
  2. Classification of Diabetic foot
  3. Classification of Diabetic foot
  4. Cusheri clinical surgery –1 Classification of Diabetic foot
  5. Classification of Diabetic foot
  6. Cushcerii foot and its pathology.
  7. .
  8. *BEST PRACTICE GUIDELINES: WOUND MANAGEMENT IN DIABETIC FOOT ULCERS
  9. Figure 1 The risk may be distinguished by general or systemic considerations versus those localized to the foot and its pathology.
  10. Figure 1 The risk may be distinguished by general or systemic considerations versus those localized to the foot and its pathology.
  11. 1- A.Cuschieri, P.A. Grace,A.Darzi,N.Borley,D.I.Rowley. Cardiovascular Disorders.Diabetic foot. Clinical surgery 2:495-499,2003.
  12. Cusheriii .