1) 5-15% of diabetics develop foot ulcers, and 70% of healed ulcers recur within 5 years. 85% of non-traumatic lower limb amputations occur due to diabetic foot ulcers.
2) The main causes of diabetic foot ulcers are neuropathy, arterial disease, and an abnormal wound healing response. Neuropathy causes loss of sensation while arterial disease increases risk of atherosclerosis.
3) Management of diabetic feet focuses on prevention through patient education, regular examination and protective footwear. Treatment involves aggressive wound care, antibiotics, and sometimes surgery or amputation in severe cases.
1. 1
THE DIABETIC FOOTTHE DIABETIC FOOT
Channa RatnatungaChanna Ratnatunga
Department of SurgeryDepartment of Surgery
University of PeradeniyaUniversity of Peradeniya
2. 2
5-15% of Diabetics develop foot5-15% of Diabetics develop foot
ulcersulcers
70% of healed Diabetic ulcer are70% of healed Diabetic ulcer are
likely to recur within 5 yearslikely to recur within 5 years
85% of non traumatic lower limb85% of non traumatic lower limb
amputations follow diabetic footamputations follow diabetic foot
ulcersulcers
DIABETIC FOOTDIABETIC FOOT
PREVALANCE AND PROGNOSISPREVALANCE AND PROGNOSIS
3. 3
Why do Diabetics sustain traumaWhy do Diabetics sustain trauma
to feet?to feet?
Extrinsic -Extrinsic - Poor visionPoor vision
Falls due to joint immobilityFalls due to joint immobility
CVAsCVAs
Oedema due to CardiacOedema due to Cardiac
causescauses
Intrinsic -Intrinsic -
4. 4
Intrinsic Causes of DiabeticIntrinsic Causes of Diabetic
Foot UlcerationFoot Ulceration
NeuropathyNeuropathy
Arterial DiseaseArterial Disease
Abnormal tissue responseAbnormal tissue response
to trauma and sepsisto trauma and sepsis
5. 5
NeuropathyNeuropathy
SensorySensory – loss of pressure,– loss of pressure,
pain, temperature and jointpain, temperature and joint
sense. i.e. removes warningsense. i.e. removes warning
signalssignals
MotorMotor – weakness and– weakness and
atrophy of intrinsic musclesatrophy of intrinsic muscles
of foot, hence altered footof foot, hence altered foot
structure and leading tostructure and leading to
deformity and altereddeformity and altered
biomechanicsbiomechanics
AutonomicAutonomic – AV shunting– AV shunting
affects maintenance of skinaffects maintenance of skin
integrity and vascular tone.integrity and vascular tone.
i.e. warm, dry, fissured footi.e. warm, dry, fissured foot
14. 14
In a Diabetic footIn a Diabetic foot
Wound healing is affected by..Wound healing is affected by..
1.1.
Growth factors deficiencyGrowth factors deficiency
Impaired fibroblast responseImpaired fibroblast response
Abnormalities of Extracellular matrixAbnormalities of Extracellular matrix
2.2. Alterations in..Alterations in..
Neuroinflammatory responseNeuroinflammatory response
Hyperaemic responseHyperaemic response
Thermoregulatory responseThermoregulatory response
15. 15
Diabetic footDiabetic foot
Infections IInfections I
Cell mediated immunity depressedCell mediated immunity depressed
Phagocytic function of multinuclearPhagocytic function of multinuclear
leukocytes affectedleukocytes affected
Leucocyte migration at microcirculatoryLeucocyte migration at microcirculatory
level is affectedlevel is affected
Hyperglycaemia associated withHyperglycaemia associated with
mycotic infections could contributemycotic infections could contribute
16. 16
Painless collection of pusPainless collection of pus
Tracking of pus along tendon sheathsTracking of pus along tendon sheaths
Staphylococcus aureusStaphylococcus aureus is commonis common
Foot compartmentsFoot compartments
Diabetic footDiabetic foot
Infections IIInfections II
Deep interosseous space
Medial plantar space
Central plantar space
Lateral plantar space
17. 17
CLINICAL ASSESSMENT OFCLINICAL ASSESSMENT OF
A DIABETIC FOOT IA DIABETIC FOOT I
Glycaemic controlGlycaemic control
SmokingSmoking
Renal diseaseRenal disease
Poor social circumstancePoor social circumstance
18. 18
CLINICAL ASSESSMENT OF ACLINICAL ASSESSMENT OF A
DIABETIC FOOT IIDIABETIC FOOT II
Extent of NeuropathyExtent of Neuropathy
Vibration sense – using tuning forkVibration sense – using tuning fork
Discriminating touch – 10g monofilamentDiscriminating touch – 10g monofilament
NylonNylon
Ankle jerksAnkle jerks
19. 19
CLINICAL ASSESSMENT OF ACLINICAL ASSESSMENT OF A
DIABETIC FOOT IIIDIABETIC FOOT III
Extent of IschaemiaExtent of Ischaemia
Pulse examination – Aortoiliac andPulse examination – Aortoiliac and
FemPop bruitsFemPop bruits
Skin color, TemperatureSkin color, Temperature
ABPIABPI
X ray medial calcinosisX ray medial calcinosis
20. 20
CLINICAL ASSESSMENT OF ACLINICAL ASSESSMENT OF A
DIABETIC FOOT IVDIABETIC FOOT IV
Extent of Neuroischaemia and sepsisExtent of Neuroischaemia and sepsis
WargnerWargner 1-5 a Global Severity Score1-5 a Global Severity Score
1:1: Superficial ulceration limited to dermisSuperficial ulceration limited to dermis
2:2: Ulceration down to fascia or bone withoutUlceration down to fascia or bone without
abscess orabscess or osteomyelitisosteomyelitis
3:3: Deep ulcers with abscess or osteomyelitisDeep ulcers with abscess or osteomyelitis
4:4: Localised gangrene confined to the toes orLocalised gangrene confined to the toes or
forefootforefoot
5:5: Gangrene requiring immediate major (aboveGangrene requiring immediate major (above
ankle) amputationankle) amputation
21. 21
Extent of InfectionExtent of Infection
Is Due to..Is Due to..
Walking on pusWalking on pus
Tracking of pus along tendonsTracking of pus along tendons
Foot compartmentsFoot compartments
SepticaemiaSepticaemia
23. 23
DIABETIC FOOTDIABETIC FOOT
Ten CommandmentsTen Commandments
For patientFor patient
Don’t walk barefootDon’t walk barefoot
Inspect the feet dailyInspect the feet daily
No hot fomentationNo hot fomentation
Correct footwearCorrect footwear
Don’t weight bear (unsupported) on the affected footDon’t weight bear (unsupported) on the affected foot
Do not sit cross-leggedDo not sit cross-legged
Don’t remove footwear during travelingDon’t remove footwear during traveling
Cut nails regularly (trim square)Cut nails regularly (trim square)
No home surgeryNo home surgery
Clean the feet twice a dayClean the feet twice a day
24. 24
DIABETIC FOOTDIABETIC FOOT
Six principles of prevention ofSix principles of prevention of
foot ulcersfoot ulcers
For PhysicianFor Physician
PPodiatric careodiatric care
PPulse examinationulse examination
PProtective shoesrotective shoes
PPressure reductionressure reduction
PProphylactic surgeryrophylactic surgery
PPreventive educationreventive education
25. 25
Protective footwearProtective footwear
Accommodation and cushioningAccommodation and cushioning
Wide toe boxWide toe box
Extra depthExtra depth
Total contact insolesTotal contact insoles
Rocker soleRocker sole
WedgingWedging
26. 26
ShoesShoes
Heel to toe length, Arch length, WidthHeel to toe length, Arch length, Width
Measure both feetMeasure both feet
Fit while weight bearingFit while weight bearing
Check for the positioning of the first MPCheck for the positioning of the first MP
jointjoint
Allow half a inch between end of theAllow half a inch between end of the
longest toe and the end of shoelongest toe and the end of shoe
Sniff fit around the heelSniff fit around the heel