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Managing the Diabetic Foot

Hemi Sinorita Sub Department of Endocrinology and Metabolism Department of Internal Medicine Medical Faculty, Gadjah Mada University Dr. Sardjito Hospital, Yogyakarta

INTRODUCTION

Foot disorders are a major source of morbidity Leading cause of hospitalization The prevalence of foot ulcers populations 2% - 10% 7-20% : amputation > 80% are potentially preventable
THE JOURNAL OF FOOT & ANKLE SURGERY, 2006.

Frygberg et al, 2006

ASSESSMENT OF THE FOOT


1. 2. 3.

4.
5. 6. 7. 8.

Neuropathy Ischaemia Deformity Callus Swelling Skin breakdown Infection Necrosis

Wound Essentials Volume 2 2007. Edmons & Foster, 2009

1. Neuropathy
Sensory loss is recognised as a major cause of diabetic foot ulceration. 4560% of all diabetic ulcerations are due to peripheral neuropathy The presentation of peripheral neuropathy is related to dysfunction of sensory, motor and autonomic nerve
Frykberg et al, 2006 Edmons & Foster, 2009

Motor neuropathy
The classical sign of a motor neuropathy : a high medial longitudinal arch prominent metatarsal pressure point of plantar forefoot
http://www.thefootandankleclinic.com/images/uploaded/footother01.jpg

Autonomic neuropathy
The classical sign of autonomic neuropathy are : Dry skin with fissuring Distended veins over the dorsum of the foot and ankle

Liau, 2009; http://upload.wikimedia.org/wikipedia/commons/thumb/1/17/DFS_bei_AVK.jpg/300px-DFS_bei_AVK.jpg

Sensory neuropathy
Can be simply detected by : Monofilaments Neurothesiometry

Results from atherosclerosis of the arteries of the leg Ulceration or necrosis is the commonest presentation of ischaemia The skin is thin, shiny, and wihout hair. There is atrophy of subcutaneus tissue.

2. Ischaemia

ABI Normal Mild obstruction *Moderate obstruction *Severe obstruction **Poorly compressible 0.91-1.30 0.71-0.90 0.41-0.70 0.40

>1.30

2006. American College of Physicians. All Rights Reserved.

Callus

Corn

Swelling, Skin breakdown, Infection, Necrosis

A. Identifying risk status

THE JOURNAL OF FOOT & ANKLE SURGERY,2006

Basic foot examination


1. 2. 3.

4.
5.

History of previous ulceration or amputation Identifying whether there is a visual or physical difficulty that prevents appropriate self-care Palpation of foot pulses dorsalis pedis and posterior tibial pulses, capillary refill testing and ankle:brachial pressure indices (ABPI) if pulses are diminished Testing for sensory loss with a 10gram monofilament or a 128Hz tuning fork Inspection of the feet for deformities (hammer toes, clawed toes or bony prominences), toenail deformities/pathology and skin pathologies such as callus and corn.

Risk 1 Low risk

No increased risk of foot problems No signs of peripheral neuropathy No peripheral vascular disease No foot deformity Annual review

Inspect feet at every office visit Podiatry care stratified to risk level Intensive patient education Detect/manage barriers to foot care Therapeutic footwear, if needed

2006. American College of Physicians. All Rights Reserved.

BASIC FOOT CARE CONCEPTS


Patient and family education assumes a primary role in prevention. Such education encompasses instruction in glucose assessment insulin administration diet daily foot inspection & care proper footwear prompt treatment of new lesions

t
THE JOURNAL OF FOOT & ANKLE SURGERY,2006

Daily foot inspection & care proper footwear

BASIC FOOT CARE CONCEPTS

Protective behaviors:
Avoid temperature extremes No walking barefoot/stockingfooted Appropriate exercise if sensory neuropathy Bicycle/swim > walking/treadmill Inspect shoes for foreign objects Optimal footwear at all times

2006. American College of Physicians. All Rights Reserved.

BASIC FOOTWEAR EDUCATION

Avoid: Pointed-toes Slip-ons Open-toes High heels Plastic Black color Too small

Diabetes Self-Management 2005; 22:33


2006. American College of Physicians. All Rights Reserved.

BASIC FOOTWEAR EDUCATION

Favor: Broad-round toes Adjustable (laces, buckles, Velcro) Athletic shoes, walking shoes Leather, canvas White/light colors between longest toe and end of shoe
Diabetes Self-Management 2005; 22:33
2006. American College of Physicians. All Rights Reserved.

Risk 2 Medium risk

Peripheral vascular disease and/or peripheral neuropathy Impaired sensation Foot deformities Every 3 to 6 months

BASIC FOOT CARE CONCEPTS

Commitment to self-care:
1.

Wash/dry daily
Avoid hot water; dry thoroughly between toes

2.

3.

4.

Lubricate daily (not between toes) Debride callus/corn avoid sharp instruments - corn plasters No self-cutting of nails if: Neuropathy, PAD, poor vision
2006. American College of Physicians. All Rights Reserved.

Risk 3 High risk


Peripheral neuropathy Peripheral vascular disease History of previous foot ulcers or amputation
Every 1 to 6 months

Risk 4 Acute foot problems


Acute foot problems, e.g. ulceration Ischaemia Infection Acute Charcot foot

Every 1 to 7 days dependent on need


International Concensus on the Diabetic Foot, 1999; Frykberg et al, 2006

B. Managing diabetic foot ulcers

Primary Goals of Treatment


1. Prevent limb loss 2. Prevention of ulceration and recurrence 3. Early recognition and treatment of diabetic foot complications 4. Maintain quality of life

Prevent limb loss

Managing diabetic foot ulcers


1. 2.

Advocate tight glycaemic control Identify aetiological factors Identify factors that have directly caused the ulcer : ill-fitting footwear. Factors that have contributed to the ulceration and can contribute to a delay in healing : peripheral neuropathy peripheral arterial disease.

Managing diabetic foot ulcers

3. Establish and quantify vascular status 4. Manage arterial risk factors BP < 130/80mmHg (drugs and lifestyle modification : salt, alcohol, weight loss, increased activity); Dyslipidaemia; Stop smoking

Managing diabetic foot ulcers


5

Rapid management of infection Foot infections are common >50% not show classic signs of infection due to a poor blood supply that reduces inflammation, redness and heat, and neuropathy that will mask pain. An increase in exudate volume-malodour

Managing diabetic foot ulcers

6. Identify wound characteristics Tissue removal is paramount for effective wound bed preparation. Inflammation or infection: prompt recognition and management of infection is vital for healing. Moisture imbalance: to prevent the wound bed becoming too dry or too moist Epithelium advancing

Managing diabetic foot ulcers

7. Establish and quantify neurological complications and pain 4560% of all diabetic ulcerations are purely neuropathic, approximately 45% are neuroischaemic

Managing diabetic foot ulcers


8. Employ offloading strategies Pressure reduction is a key aspect at preventing and healing. Therapeutic footwear has also been shown to have a beneficial role in the primary and secondary prevention of diabetic foot ulcers

Managing diabetic foot ulcers

9. Multidisciplinary team approach : physician, podiatrist, specialist nurse, dietician, radiologist, vascular surgeon, and orthopaedic surgeon 10. Structured education

THE JOURNAL OF FOOT & ANKLE SURGERY,2006

terima kasih

Depth Classification

Definition

Treatment Patient education, accommodative footwear, regular clinical examination Offloading with total contact cast (TCC), walking brace, or special footwear

At-risk foot, no ulceration Superficial ulceration, not infected

Deep ulceration Surgical debridement, wound exposing tendons care, offloading, cultureor joints specific antibiotics Extensive ulceration or abscess Debridement or partial amputation, offloading, culture-specific antibiotics

fBrodsky JW: The diabetic foot. In: Coughlin MJ, Mann RA, eds. Surgery of the Foot and Ankle. St Louis, Mo: Mosby; 1999: 911.

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