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The Role of the Podiatrist in Diabetic Foot Care
- 1. THE ROLE OF THE PODIATRIST IN THE CARE OF THE DIABETIC FOOT By Zoe Boulton
- 2. Contents Assessment of the diabetic foot Features of ulcerations Debridement Dressings Biomechanics Offloading
- 3. General Role of the Podiatrist Identification of patients who are at risk of developing foot problems Establish a risk score for patient as per NICE guidelines (Low, Moderate, High) Providing appropriate treatment/ assessment Education to patients and other professionals Work as part of larger multidisciplinary team
- 4. Vascular assessment Palpate pulses or use Doppler Dorsalis Pedis Posterior Tibialis
- 5. ABPI Can be useful in determining level of ischaemia Carried out when ischaemia is suspected Values of: <0.8: the foot is at risk of ulceration <0.5: the foot is critically ischaemic Caution: May give false readings in diabetic patients due to calcification of arteries consider pallor on elevation and dependant rubor also.
- 6. Neurological Assessment Monofilament 8/10 or below neuropathy
- 7. Neurothesiometer Above 25 volts indicates presence of peripheral neuropathy
- 8. Typical features of Ulceration Neuropathic Ischaemic Pulses Bounding Diminished/absent Pain None/minimal High degree of pain Location of Ulceration Pressure areas Borders of feet Callus Often large amounts Minimal
- 9. Assessment of Diabetic Foot Presence of Infection (bacteria and fungi) Ulceration/ foreign bodies Pre-ulcerative areas Deformity Oedema Skin quality Footwear
- 10. Debridement Sharp debridement Allows true extent of ulcer to be revealed Allows healing with removal of slough and dead tissue Maggots
- 11. Case Study Patient presented after walking on a gripper rod.
- 12. This was also discovered …
- 14. Dressings Wound bed Consider patient Exudate management Moist healing environment Negative Pressure dressings Not the be all and end all !!
- 15. Biomechanics of foot Altered foot function can be a cause of ulceration eg hallux limitus. Forefoot equinus Glycosylation of tissues and amount of deformity in foot can indicate severity of neuropathy
- 16. Offloading Felt Bespoke insoles and footwear- rocker soles PRAFO Aircast
- 17. Conclusion Podiatrists work as part of a multidisciplinary team when managing the diabetic foot The diabetic foot MUST be managed as part of a wide team involving a number of specialities. We all aim to facilitate healing and ensure the best care for the patient Thanks for listening
Notes de l'éditeur
- When considering any aspect of a diabetic foot it is vital that there is a MDT approach podiatrists need glucose levels to be optimum to encourage healing but also need footwear to be bespoke in man cases. Also need community staff both pods and nurses for redressing etc.
- If palpable then fair to say not too bad but use as part of clinical pic as neuro feet often bounding pulses. These are two main pulses checked can also use peroneal as another indicator.
- Monofilament detects dysfunction of small fibres this is pain and temp through the alpha delta nerve fibres and c fibres is repeatable and exerts 10g of pressure each time must be allowed to buckle and should be held there for 1 sec. Get patient to close eyes as many will want to please practitioner !!!
- Neurothesiometer: rested on apex of digit (usually 1st) detects LARGE fibre neuropathy .........
- Table indicating the difference in types of ulceration (MOLLIE MAY HAVE INCLUDED THIS )
- The presence of tidea pedis infection aka (althetes foot) needs to be addressed in a diabetic as can lead to secondary bacteria infections. Found interdigital with red skin, odour, peeling skin ?itch (neuro) toes tend to be fixed/ close together – topical treatment Obvious one and check shoesAreas such as in picture one can indicate that that area is receiving high amounts of pressure and tissue exhibit extravasation which if left would lead to ulceration requires debriding and offloading. However this could also be an ulceration under callus. Deformity eg charcot but also toe deformity such as claw/ hammer and mallet as this increases pressure to areas like wise HAV etc. Indicator of systemic conditions but also consideration for footwear as wont be able to wear off the shelf.Is it dry? Fissured? Indicatiors of neuropathy and patient care for foot health, also too much tape thin skin in elderly etc. Need referral to orthotist ?
- Allows healing and drainage of wound Removal of non- viable tissueCallus will often build up over wounds and form a plug essentially. Maggots are an alternative in presence of adherent slough but use cautiously due to cost
- Dressing evidence is very poor quality. Often our dressing choice is determined on the observation of the wound bed and then dressed accordingly. Granulating wounds may simply require protection where as sloughly wounds will require dressings that encourage removal of slough and allow hyealing of the wound. Necrosis – keep dry. Important to consider patient high exduate levels, if working ?Important to manage exudate to prevent excouriation.