Diabetic Foot 12 Des

8/14/2019 Diabetic Foot 12 Des

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Managing the Diabetic Foot

Hemi SinoritaSub Department of Endocrinology and Metabolism

Department of Internal MedicineMedical Faculty, Gadjah Mada UniversityDr. Sardjito Hospital, Yogyakarta


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INTRODUCTION

Foot disorders are a major source ofmorbidityLeading cause of hospitalization

The prevalence of foot ulcerspopulations 2% - 10%

7-20% : amputation> 80% are potentially preventable

THE JOURNAL OF FOOT & ANKLE SURGERY, 2006.


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Frygberg et al , 2006


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ASSESSMENT OF THE FOOT

1. Neuropathy2. Ischaemia

3. Deformity4. Callus5. Swelling6. Skin breakdown7. Infection8. Necrosis

Wound Essentials Volume 2 2007. Edmons &Foster, 2009


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1. NeuropathySensory loss is recognised asa major

cause of diabetic foot ulceration.45 60% of all diabetic ulcerations are due

to peripheral neuropathy

The presentation of peripheralneuropathy is related to dysfunction ofsensory, motor and autonomic nerve

Frykberg et al, 2006 Edmons & Foster, 2009


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Motor neuropathy

The classical sign of amotor neuropathy :a high mediallongitudinal arch

prominent metatarsal

pressure point of plantar

forefoot

http://www.thefootandankleclinic.com/images/uploaded/footother01.jpg


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Autonomic neuropathy

The classical sign of autonomic neuropathy are :Dry skin with fissuring

Distended veins over the dorsum of the footand ankle

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


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Sensory neuropathy

Can be simply detected by :MonofilamentsNeurothesiometry


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2. IschaemiaResults from atherosclerosis of the arteries of the legUlceration or necrosis is the commonest

presentation of ischaemia The skin is thin, shiny, and wihout hair. There is atrophy of subcutaneus tissue.


12/45 2006. American College of Physicians. All Rights Reserved.

ABINormal 0.91-1.30Mild obstruction 0.71-0.90*Moderate obstruction 0.41-0.70*Severe obstruction 0.40**Poorly compressible >1.30


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Callus


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Corn


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Swelling, Skin breakdown, Infection, Necrosis


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A. Identifying risk status


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Basic foot examination

1. History of previous ulceration or amputation2. Identifying whether there is a visual or physical difficulty

that prevents appropriate self-care3. Palpation of foot pulses dorsalis pedis and posterior tibial

pulses, capillary refill testing and ankle:brachial pressureindices (ABPI) if pulses are diminished

4. Testing for sensory loss with a 10gram monofilament or a128Hz tuning fork

5. Inspection of the feet for deformities (hammer toes,clawed toes or bony prominences), toenaildeformities/pathology and skin pathologies such as callusand corn .


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Risk 1

Low riskNo increased risk of foot problemsNo signs of peripheral neuropathyNo peripheral vascular diseaseNo foot deformity

Annual review


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Inspect feet at every office visitPodiatry care stratified to risk level

Intensive patient educationDetect/manage barriers to foot care

Therapeutic footwear, if needed

2006. American College of Physicians. All Rights Reserved.


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Patient and family educationassumesa primary role in prevention.Such education encompassesinstruction in

glucose assessmentinsulin administrationdietdaily foot inspection &

care proper footwear prompt treatment of newlesions t

THE JOURNAL OF FOOT & ANKLE SURGERY,2006

BASIC FOOT CARE CONCEPTS


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Daily foot inspection & care proper footwear


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Protective behaviors: Avoid temperature extremesNo walking barefoot/stocking-footed

Appropriate exercise if sensoryneuropathyBicycle/swim >

walking/treadmill

Inspect shoes for foreignobjectsOptimal footwear at all times



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BASIC FOOTWEAR EDUCATION

Avoid:Pointed-toesSlip-onsOpen-toesHigh heelsPlasticBlack color

Too small

Diabetes Self-Management 2005; 22:33



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BASIC FOOTWEAR EDUCATION

Favor:Broad-round toes

Adjustable (laces, buckles,

Velcro) Athletic shoes, walking shoesLeather, canvas

White/light colors between longest toe and

end of shoe

Diabetes Self-Management 2005; 22:33



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Risk 2 Medium risk

Peripheral vascular disease and/or peripheralneuropathyImpaired sensationFoot deformities

Every 3 to 6 months


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Commitment to self-care:

1. Wash/dry daily Avoid hot water; dry

thoroughly between toes

2. Lubricate daily (notbetween toes)3. Debride callus/corn

avoid sharp instruments- corn plasters

4. No self-cutting of nailsif: Neuropathy, PAD,

poor vision 2006. American College of Physicians. All Rights Reserved.


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Risk 3High risk

Peripheral neuropathyPeripheral vascular disease

History of previous footulcers or amputation

Every 1 to 6 months


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Risk 4

Acute foot problems Acute foot problems, e.g. ulcerationIschaemiaInfection

Acute Charcot foot

Every 1 to 7 daysdependent on need

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


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B. Managing diabetic foot ulcers


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Primary Goals of Treatment

1. Prevent limb loss

2. Prevention of ulceration and recurrence3. Early recognition and treatment ofdiabetic foot complications

4. Maintain quality of life


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Prevent limb loss


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Managing diabetic foot ulcers

1. Advocate tight glycaemic control 2. Identify aetiological factors Identify factors that have directly causedthe ulcer : ill-fitting footwear .Factors that have contributed to theulceration and can contributeto a delay in healing :

peripheral neuropathy peripheral arterial disease .


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3. Establish and quantify vascular status4. Manage arterial risk factors

BP < 130/80mmHg (drugs and lifestylemodification : salt, alcohol, weight loss,increased activity); Dyslipidaemia;

Stop smoking


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5 Rapid management of infection

Foot infections are common>50% not show classic signs ofinfection due to a poor bloodsupply that reduces

inflammation, redness and heat,and neuropath y that will mask pain. An increase in exudate volume-malodour


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t


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6. Identify wound

characteristics Tissue removal isparamount for effective

wound bed preparation.Inflammation or infection :prompt recognition andmanagement of infection is

vital for healing.Moisture imbalance: toprevent the wound bedbecoming too dry or toomoistEpithelium advancing


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7. Establish and quantify neurologicalcomplications and pain45 60% of all diabetic ulcerations are purelyneuropathic, approximately 45% are

neuroischaemic


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8. Employ offloading strategiesPressure reduction is a key aspect at preventingand healing. Therapeutic footwear hasalso been shown to have a beneficial

role in the primary

and secondary prevention of diabetic foot ulcers
http://www.emedicine.com/orthoped/images/1230552-1234396-374.jpghttp://www.emedicine.com/orthoped/images/1230552-1234396-374.jpg


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t t

THE JOURNAL OF FOOT & ANKLE SURGERY,2006


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terima kasih


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DepthClassification Definition Treatment

0 At-risk foot, no

ulceration

Patient education,accommodative footwear,regular clinicalexamination

1

Superficialulceration, notinfected

Offloading with total contactcast (TCC), walking brace,or special footwear

2

Deep ulcerationexposing tendons

or joints

Surgical debridement, woundcare, offloading, culture-

specific antibiotics

3Extensive ulceration

or abscess

Debridement or partialamputation, offloading,culture-specific antibiotics

Diabetic Foot 12 Des

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