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LOWER EXTREMITY

COMPLICATIONS AND

MANAGEMENT IN PATIENTS

WITH DIABETES

Don Curtis, DPM, FACFAS

Midwestern University

www.mwuclinic.com

623-572-6160

TOTAL PREVALENCE OF DIABETES

Data from the 2011 National Diabetes Fact Sheet (released Jan. 26, 2011)

TOTAL PREVALENCE OF DIABETES

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MORBIDITY AND MORTALITY

COMPLICATIONS

� Heart disease and stroke� Heart disease was noted on 68% of diabetes-related death

certificates >65 years.

� Stroke was noted on 16% of diabetes-related death certificates > 65 years.

� Adults with diabetes have heart disease death rates about 2 to 4 times higher than adults without diabetes.

� The risk for stroke is 2 to 4 times higher among people with diabetes.

� High blood pressure� Self reported DM, >20 years:

� 67% had HTN ≥ 140/90 mmHg or used prescription medications HTN.


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COMPLICATIONS

� Blindness� Diabetic retinopathy is an important cause of blindness, and occurs as

a result of long-term accumulated damage to the small blood vessels in the retina.

� Diabetes is the leading cause of new cases of blindness among adults aged 20–74 years.

� In 2005-2008, 4.2 million (28.5%) people with diabetes aged 40 years or older had diabetic retinopathy.

� Kidney disease� Diabetes is the leading cause of kidney failure, 44% of new cases in

2008.

� In 2008, a total of 202,290 people with end-stage kidney disease due to diabetes were living on chronic dialysis or with a kidney transplant in the United States.


COMPLICATIONS

� Nervous system disease (Neuropathy)� About 60% to 70% of people with diabetes have mild to severe

forms of nervous system damage.

� Amputation� More than 60% of nontraumatic lower-limb amputations occur in

people with diabetes.� Combined with reduced blood flow, neuropathy in the feet

increases the chance of foot ulcers, infection and eventual need for limb amputation.

� Death� The overall risk of dying among people with diabetes is at least

double the risk of their peers without diabetes.


COST OF DIABETES


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LOWER EXTREMITY DIABETIC

FOOT EXAM�Dermatologic Exam:

� Skin Appearance� Color, texture, turgor, quality, dry skin

and fissures

� Calluses � Nails

� Onychomycosis� Paronychia

� Ulcerations� Markers for Diabetes

� Shin Spots – diabetic dermopathy

� Necrobiosis Lipoidica � Bullosum diabeticorum

� Granuloma annulare

� Anthosis nigricans

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WAGNER WOUND CLASSIFICATION

� Wagner Grading System� Grade 0: No open lesions� Grade 1: Superficial Ulcer � Grade 2: Deep Ulcer

� Involves ligament, tendon, joint capsule or fascia � No abscess or osteomyelitis

� Grade 3: Deep ulcer with abscess, osteomyelitis, or joint sepsis

� Grade 4: Local Gangrene of forefoot or heel � Grade 5: Extensive gangrene of entire foot

� Reference � Wagner (1987) Orthopedics 10:163-72

LOWER EXTREMITY

DIABETIC FOOT EXAM�Vascular Examination

� Palpation of Pulses� Handheld Doppler Examination� Skin/Limb color changes

� Cyanosis, erythema,

� Elevation pallor – dependent rubor

� Edema� Temperature gradient� Integumentary Changes

� Skin atrophy

� Thin, smooth, parchment-like � hair growth absent.

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VASCULOPATHY

� Signs and symptoms of poor circulation of the lower extremities include:� Cool or cold feet

� Pale or blue color of toes

� Slow return of color after squeezing toes

� Decreased leg hair in men

� Calf pain with walking

� Slow healing

ACCELERATED ATHEROSCLEROSIS

LOWER EXTREMITY

DIABETIC FOOT EXAM

�Neurological Exam� Vibration perception:

� Tuning fork 128cps

� Light Pressure:� Semmes-Weinstein 10 g

monofilament

� Light Touch� Two Point Discrimination� Pain: pinprick (sterile)� Temperature perception� Deep Tendon Reflexes� Clonus, Babinski and Romberg

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SENSORY NEUROPATHY

� ‘Pain arising as a direct consequence of abnormalities in the somatosensory system in people with diabetes.’� International Association for

the Study of Pain

� A diagnosis of exclusion and is a clinical diagnosis� Relying on the patient’s

description� A careful clinical history� A thorough neurological and

vascular exam is essential

SUBJECTIVE COMPLAINTS

� Burning� Cramping

� Aching� Tingling

� Stinging� Walking on marbles� Knife-like

� Warm/Cold� Numbness

� Hypersensitivity� Cramping

� Walking on hot sand

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AUTONOMIC NEUROPATHY

� Cardiovascular� sudden death, silent MI, decreased

exercise tolerance, CHARCOT?

� Genitourinary � erectile dysfunction, urinary retention

� Gastrointestinal� gastroparesis, anorexia, nausea,

vomiting, diarrhea, constipation

� Cutaneous� sweat disturbances, reduced nutrient

delivery, reduced blood flow

MOTOR NEUROPATHY

� Muscle weakness/wasting

� Limitation of joint motion� Glycosylation of collagen limits

flexibility� Range of motion is diminished� Ankles, subtalar joints, 1st mtpj’s

commonly affected

� Common symptoms:� Foot drop / loss in function� Tripping / gait disturbances� Deformities (hammertoes)� Equinus

LOWER EXTREMITY

DIABETIC FOOT EXAM

�Musculoskeletal Exam� Biomechanical Abnormalities� Structural Deformities

� Bunion, Hammertoes, Tailor’s Bunion

� Flat feet/High arches� Charcot Deformity

� Prior Amputations� Limited Joint Mobility� Achilles Contracture� Gait Exam� Muscle Strength Testing� Plantar Pressure Assessment

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LOWER EXTREMITY

DIABETIC FOOT EXAM

�Footwear Examination� Type of Shoe

� Athletic, dress, sandal

� Fit� Too loose can cause friction blisters

� Too tight can cause pressure ulcers

� Depth of toe box� Wear pattern

� Shows high pressure points

� Lining� Foreign body� Supports/orthotics

RISK STRATIFICATION

� Category Risk Profile Eval Frequency� 0 Normal q 12 months� 1 Periph Neurop q 6 months� 2 LOPS, deformity,

+/- PAD q 3 months� 3 Previous ulcer or amp q 1-3 months

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American Diabetes Association. Diabetes 1996 Vital Statistics.

SURVIVAL RATES AFTER AMPUTATION

�After 1 major lower-extremity amputation� 3-year survival rate is 50%� 5-year survival rate is 40%

�Contralateral amputation� 42% of patients within 1 to 3 years after

first amputation� 56% of patients within 3 to 5 years after

first amputation

5-YEAR SURVIVAL RATES AFTER AMPUTATION

�Add Some Perspective

2007: Armstrong et al; Are diabetes related wounds and amputations worse than cancer?

RATES OF LOWER EXTREMITY

AMPUTATIONS

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RATES OF LOWER EXTREMITY

AMPUTATIONS

3RD DIGIT OSTEOMYELITIS

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TEAM APPROACH TO DIABETIC

FOOT CARE

PATIENT CARE INSTRUCTIONS

� 1. Inspect feet daily-watch for�Color changes (redness, streaking, blue, pale)�Swelling�Temperature changes (increased or decreased)�Sensation changes�“Hot Spots” - red areas due to friction�Cracks, sores, blisters, ulcers�Toenail problems�Drainage and Odor

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� 2. Never walk barefoot� Even indoors

� Always wear socks and shoes together� Make sure shoes fit properly

� Inspect shoes for foreign objects

� 3. Check water temperature with elbows prior to entering� Dry well between toes

� 4. Use lotions or creams daily� Do not apply between toes


� 5. Don’t treat wounds, corns, or calluses yourself.� Unless directed by your Podiatrist

� 6. Don’t smoke or quit smoking.� Smoking causes decreased blood flow and reduced healing potential

�CONTROL YOUR DIABETES!!

REFERENCES

� Diabetic Foot Disorders: A Clinical Practice Guideline. Frykberg et al. Journal of Foot & Ankle Surgery Vol 45, Number 5, September/Ocober 2006 Supplement.

� 2012 Infectious Disease Society of America; Clinical Practice Guideline for the Diagnosis & Treatment of Diabetic Foot Infections (IDSA Guidelines). Lipsky et al. Clinical Infectious Diseases 2012:54 (12):132-173.

� The Diagnosis of Charcot Foot. Rogers & Bevilacqua. Clinics in Podiatric Medicine & Surgery 25(2008) 43-51.

� Medical Imaging of the Diabetic Foot. Loredo et al. Clinics in Podiatric Medicine & Surgery 24(2007) 397-424.

� Painful Diabetic Peripheral Neuropathy: Consensus Recommendations on Diagnosis, Assessment & Management. Tesfaya et al. Diabetes/Metabolism Research & Reviews 2011; 27:629-638

� Are Diabetes-Related Wounds & Amputations Worse Than Cancer? Armstrong et al. International Wound Journal 2007 Vol.4 No.4

� Shoes, Orthoses & Prostheses for Partial Foot Amputations & Diabetic Foot Infections. Janisse et al. Foot & Ankle Clinics of North America 15(2010) 509-523

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