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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.
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5. 6. 7. 8.
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
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
Callus
Corn
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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.
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
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THE JOURNAL OF FOOT & ANKLE SURGERY,2006
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
Avoid: Pointed-toes Slip-ons Open-toes High heels Plastic Black color Too small
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.
Peripheral vascular disease and/or peripheral neuropathy Impaired sensation Foot deformities Every 3 to 6 months
Commitment to self-care:
1.
Wash/dry daily
Avoid hot water; dry thoroughly between toes
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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.
Peripheral neuropathy Peripheral vascular disease History of previous foot ulcers or amputation
Every 1 to 6 months
Acute foot problems, e.g. ulceration Ischaemia Infection Acute Charcot foot
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.
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
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
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
7. Establish and quantify neurological complications and pain 4560% of all diabetic ulcerations are purely neuropathic, approximately 45% are neuroischaemic
9. Multidisciplinary team approach : physician, podiatrist, specialist nurse, dietician, radiologist, vascular surgeon, and orthopaedic surgeon 10. Structured education
terima kasih
Depth Classification
Definition
Treatment Patient education, accommodative footwear, regular clinical examination Offloading with total contact cast (TCC), walking brace, or special footwear
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.