DIABETES India is the country with many diabetic

people. Diabetes is not a single disease but a group of

metabolic disorders sharing common underlying features of hyperglycemia.

Diagnostic criteria

1. Random blood glucose > 140mg/dl2. Fasting blood glucose > 126mg/dl3. Abnormal glucose tolerance test: Blood glucose >200 mg/dl 2hr after of

standard carbohydrate load. Person with blood glucose greater than 100mg/dl and less

than 126mg/dl are known as “pre diabetics” who in progress get diabetes over time.

Classification

• Type 1 • Auto immune disease characterized by

destruction of beta cells of pancreas. • 5 to 10% cases• Mostly seen < 20 yrs of age.

• Type 2 • Combination of peripheral resistance to

insulin &inadequate secretion response to insulin.

• 90 to 95% cases• Adult onset• Although of adult onset now a days seen in

obese children at alarming rate.

Complications of diabetes

• Acute metabolic complications:1>Diabetic ketoacidosis2>Hyperosmolar nonketotic coma3>Hypoglysemia(If excess insulin is given)

• Late systemic complications:1>Atherosclerosis2>Diabetic microangiopathy3>Diabetic nephropathy4>Diabetic neuropathy5>Diabetic retinopathy6>Diabetic ulcers & infections

Diabetic footIntroduction:•one of the complication of diabetes

Incidence:•Estimated that 10 to 25% of diabetic patients develop some or other foot problem in their lifetime.

•5 to 15% require a lower limb amputation

Presentation Of Diabetic Foot

•Shape: change in shape lead to areas of pressure on prominent metatarsal heads,hammertoes,collapsed mid foot.

•Callus: Callus is seen with excessive wear &tear of tissue.

•Skin: Skin is dry and without sweating due to autonomic neuropathy. Crack easily & a route of infection.

•Sensations: Loss of sensations which are assessed by traditional modalities like ankle jerks, tendon reflex .

•Pain sensation :reduced & is assessed by biosthesiometer& nylon monofilament.

Etiopathology of diabetic foot

• Truly multi factorial but one may predominate others.

• Factors are 1. Neuropathy2. Macrovascular disease3. Microvascular disease 4. Connective tissue abnormalities5. Infections6. Hematological disturbances

Neuropathology• Glove & stocking type• Sensory, motor, autonomic all nerves

involved. Causes: 1]Metabolic factor(Due to hyper glycemia) 2]Microvascular disease Effects: 1]Extrinsic 2]Intrinsic

Extrinsic:• Loss of somatic sensations of plantar aspect cause ulcer by: ill fitting shoe,toe nail, thermal injury,foreign body….• Pain is not perceived ,So damage continues,• Established ulcer is the end point.

Intrinsic:• Causes smooth motor neuropathy Weakness of intrinsic

muscles Abnormal movements of small bones &joint subluxation Visceral neuropathy cause loss of proprioception Patient keeps on walking on aching foot (which is not known to him) Stretching of joint capsules & bony changes take place With continuous shear pressure cause callus & ulcer formation.

VascularMacrovascular

• Diabetics are 4 to 7 times more prone for atherosclerosis than normal.

• Mostly affect tibial and peroneal arteries.

• Reduced oxygen partial pressure

• Vascular calcification seen in x-ray & angiography.

Microvascular• Structural abnormalities in: 1]Basement membrane 2]Endothelial function

• Basement membrane: Leads to defect in movement of leucocytes & macromolecules.

• Endothelial Function :Defect leads to poor tissue perfusion & play important role in ulceration.

Infections

• Skin cracks & fungal infection between toes are route of infection.

• Gram –ve & +ve aerobes & anaerobes are noted.

Causation of infections increased in diabetes due to:

1. Deficiency of cell mediated immunity2. Impaired chemotaxis3. Impaired phagocytosis & opsonization.

Connective Tissue Disorders

• Hyperglycemia affect structure and function of proteins like keratin, collagen

Changes in them and structures become weak & inelastic affect bone structure of foot

Ulcers.

Hematological Disturbances

• They cause:1. Ischemia 2. Ulceration3. Spread of infections4. Red cell deformities ---Hypercoagulability &increased plasma

viscocity.5. All these increase chances of infections.

Prevention•Patient education is central aim•Daily examination of foot for any ulcer and footwear for foreign body.•Creams applied must be non allergic & without perfume.•Chiropody is advised.•Cushions at pressure points must be used.•Never walk barefoot.• Special types of shoes are adviced.

Management & Treatment • Chiropody:• Special care of foot, removal of callus with scalpel. Padding

for prominent areas.

• Orthotics:• Total contact plaster casts. Tailor made temporary shoes are

used.

• Small Surgeries:• If conservations fail small surgeries are done. Small bones are

checked.

• Eradication of infections:• Antibiotics used Debridement and regular dressings done.

FutureIn spite of all these measures patients land up in amputations

They require rehabilitation with prosthetic limbs.

“When there is a will There is surely a way”