the diabetic foot in primary care andre sookdar
DESCRIPTION
TRANSCRIPT
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The Diabetic Foot in Primary Care
Andre Sookdar
Class of 2013
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Objectives
• Epidemiology• Clinical Presentation• Prevention• Management• Insulin Initiation
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Definition
WHO• The foot of a Diabetic Patient that has the
potential risk of pathologic consequences including infection, ulceration and/or destruction of deep tissues associated with neurologic abnormalities, various degrees of peripheral vascular disease and/or metabolic complications of diabetes in the lower limb.
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Definition
Any foot pathology that results from Diabetes or its long-term complications
(Boulton. 2002). Diabetes, 30 : 36, 2002
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Epidemiology
• WHO estimates approx 60,000 persons in T&T were diabetic in 2000
• Projected increase to 125,000 by 2030• MOH estimates 1 in 5 adults are diabetic;
as much as 175,000• 450 children with Type 1 DM• More prevalent in the East Indian
community, but 33% of African attendees of the public health services are both Diabetic and Hypertensive
• Cause for about 25% Hospital Admissions
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Epidemiology
• More than 450 non traumatic lower limb amputations in 2010
• DM foot problems account for 14% of admissions, 29% of bed occupancy
• 50% of persons who had lower limb amputations develop depression; 20% die within 2 years
• V Naraynsingh et al - 822 clinic patients who had amputations between 2000-2004 reviewed; 515 (80%) due to DM
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Risk Factors
• Age• Duration of DM
>10yrs• Gender M>W• Poor glycemic
control• Social situation and
support• Obesity• Alcohol• Smoking• Depression or
Mental illness• Previous Ulcer• Trauma• Retinopathy• Nephropathy• Willful self neglect
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Pathology
Neuropathy• Sensory: lack of sensation Repetitive
Trauma• Motor: Changes in Foot anatomy
Pressure Points• Autonomic: Lack of sweat Dry Skin
Distended veins AV Shunting
Osteoarthropathy: Changes in foot structure Charcot’s foot
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Pathology
Callus: separates dermis Ulcer Formation
Infection: Disruption of skin barrier, warmth and moisture
Peripheral Vascular Disease: reduced blood flow decreased O2 supply increased risk of infection and poor healing
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Diabetic Foot Assessment
• History• Examination• Investigations• Risk Assessment
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History
General Hx• Medical Hx• Surgical Hx• Drug Hx• Allergies
Foot History• PC for Foot• Neuropathic vs
Ischaemic Pain• Daily activities &
use• Foot Care• Callus Formation• Deformities• Prev Surgeries• Skin & Nail
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Ulcer History
• Site, size, shape, duration, odor, type• Precipitating event or Trauma• Recurrence• Infection• Hospitalization & Treatment• Wound Care• Patient Compliance• Previous Foot Trauma or Surgery• ? Charcot’s Foot
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Examination
• General Examination• Inspection• Palpation• Neurological Assessment• Footwear Assessment
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General Examination
• Cardiovascular• Respiratory• Abdominal• Eyes : Visual Acuity, Fundi• Systemic Signs of Infection
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Inspection
• Skin: dry, fissures, hair loss, dilated veins, ulcers, bullae, fungal infections
Necrobiosis Lipoidica Diabeticorum, Diabetic Dermopathy
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Inspection
• Corns and Calluses• Nails: Thickened or Atrophic,
Ingrown ,Colour of nail bed, Discharge, Fungal infections
• Oedema: poor fitting shoes, impedes healing
Indicator of CV, Renal status, venous insufficiency, infection, Gout, Trauma, DVT, lymphoedema and many more
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Inspection
• Deformity: abnormal pressure distribution• Pes Cavus• Fibrofatty padding depletion• Hammer toes• Claw Toes• Hallux Valgus• Charcot Foot• Iatrogenic
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Inspection
• Colour • Red – Cellulitis, Critical ischaemia,
Osteomyelitis, Gout, Burn• Blue – Cardiac Failure, Venous insuffiency• Black – Necrosis, Ischaemia, Emboli,
Bruise, Melanoma, Henna, Dye
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Palpation
• Pulses – Dorsalis Pedis, Posterior Tibial
Presence of either makes ischaemia unlikely
If neither are present Doppler
Dependent Rubor PVD• Temperature
Hot Infection, Charcot, Bony or Soft tissue Trauma, Gout, DVT
Cold Ischaemia (acute and chronic), Cardiac Failure
• Oedema• Crepitus Gas Gangrene
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Neurologic Assessment
• Motor Neuropathy• Classically, high medial longitudinal arch
prominent metatarsal heads and pressure points over the plantar forefoot
• Assess dorsiflexion for foot drop (common peroneal nerve palsy)
• Autonomic Neuropathy• Dry skin, fissures, distended veins• Stocking distribution
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Neurologic Assessment
• Sensory Neuropathy• Monofilament test buckles @10g• Vibration 128 Hz tuning fork• Temperature• Light Touch• Pain• Eyes closed, non-touch
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Footwear Assessment
• Examine both shoes and socks
• Length, breadth, depth
• Heel height• Lace/strap vs slip-
on• Shoe lining• Foreign bodies• Wear and tear
• Snug fit, loose or tight?
• What other shoes does the patient wear?
• Sock size, seams, tightness, holes, absorbency?
• Cardboard cutout test
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Investigations
• Laboratory• Radiological• Vascular• Neurological• Foot Pressures
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Laboratory
• CBC• RFT• LFT• RBS, HbA1C• Lipid Profile• CRP• Wound Cultures• Blood and Urine Cultures
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Radiological
• Plain Films• Osteomyelitis• Fractures• Dislocations• Charcot foot• Foreign Body• Gas• CT • Technetium bone scan – early detection• MRI – Soft tissue
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Vascular
• Doppler; pulses, Ankle Brachial Pressure Index
• <1 ischaemia• Patients with arterial calcification
elevated systolic pressure, hence the pressure index may be >1 in spite of ischaemia
• Investigate Popliteal and Femoral Arteries
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Neurological
• Neurothesiometer• Varying vibratory stimulus
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Foot Pressures
• Plantar pressure measurement devices• Ink and paper
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Classification
• University of Texas Wound Classification System of Diabetic Foot Ulcers
• Wagner• Edmonds
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Edmonds Classification
• Based on natural progression• Stage 1: Normal or Low Risk Foot• Stage 2: High-Risk Foot• Stage 3: Ulcerated Foot• Stage 4: Infected Foot• Stage 5: Necrotic Foot• Stage 6: Unsalvageable Foot
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Edmonds Classification
• Stage 1 – The foot is not at riskSensation and pulses goodNo deformities, calluses or swelling
• Stage 2 – One or more risk factors for ulceration
Neuropathy and Ischaemia are the main risk factors
Deformity, oedema and callus may not lead to ulceration unless one or both of the main risk factors are present
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Edmonds Classification
• Stage 3 – Skin breakdown occurs usually as an ulcer, but injuries such as grazes, bruises and blisters can eventually become ulcers
• Stage 4 – Infection can complicate both the neuropathic and ischaemic foot
• Stage 5 – Necrosis can further lead to tissue destruction
• Stage 6 – The foot cannot be saved
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Edmonds Classification
Exceptions to this classification include • Charcot’s foot• Neuropathic fractures• Painful neuropathy
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Management
• Regular inspection and examination• Multidisciplinary team• Patient education• Assess risk of foot• Non ulcer pathology• Ulcers and related pathology
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Patient Education
• Optimum Glycemic control• Management of co-morbid conditions• Stop Smoking• Warning signs
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Foot Care
• Daily Routine and Inspection• Between toes and below foot• Nail Care: trim wet, straight across, proper
clippers (NO KNIVES)• Skin Care: Moisture, Callus• Footwear: Proper fit, clean• Avoid excessive heat (Radiators, Hot
water, hot pitch)• Avoid OTC Corn/Callus medications• NEVER WALK BAREFOOT
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Non Ulcer Pathology
• Calluses & Nails – Podiatrist• Skin pathology• Foot deformities – Surgical / Orthopedic
consult
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Ulcer Pathology
• Treat the Cause(s) and co-morbid factors• Psychosocial Factors• Relief of mechanical pressure and protect
ulcer from stress• Local Wound Care• Treatment of Infection: Abx (Broad
Spectrum, multiple), Drainage, Debridement
• Moisture control: Dressings• Outpatient or Inpatient Care
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Ulcer Pathology
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Ulcer Pathology
• Low Threshold for Referral• Stage 3 and above associated with poor
control
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Conclusion
• Diabetic foot is a serious complication• Associated with poor control• Prevention requires vigilance and patient
education• Treated by a multidisciplinary team
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Thank You
• Questions?
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References
1. Edmonds ME, Foster AVM, Sanders LJ. A Practical Manual of Diabetic Foot Care 2nd Ed. Blackwell Publishing 2008
2. Radwan M. The Diabetic Foot: An Overview [Internet] cited 1st June 2012 Available from: www.mansdf.edu.eg/Videos_presentations/DF-overview.pdf
3. National Institute of Health. Feet can last a Lifetime NIH and CDC. 2010