The Diabetic Foot in Primary Care

Andre Sookdar

Class of 2013

Objectives

• Epidemiology• Clinical Presentation• Prevention• Management• Insulin Initiation

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.

Definition

Any foot pathology that results from Diabetes or its long-term complications

(Boulton. 2002). Diabetes, 30 : 36, 2002

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

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

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

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

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

Diabetic Foot Assessment

• History• Examination• Investigations• Risk Assessment

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

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

Examination

• General Examination• Inspection• Palpation• Neurological Assessment• Footwear Assessment

General Examination

• Cardiovascular• Respiratory• Abdominal• Eyes : Visual Acuity, Fundi• Systemic Signs of Infection

Inspection

• Skin: dry, fissures, hair loss, dilated veins, ulcers, bullae, fungal infections

Necrobiosis Lipoidica Diabeticorum, Diabetic Dermopathy

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

Inspection

• Deformity: abnormal pressure distribution• Pes Cavus• Fibrofatty padding depletion• Hammer toes• Claw Toes• Hallux Valgus• Charcot Foot• Iatrogenic

Inspection

• Colour • Red – Cellulitis, Critical ischaemia,

Osteomyelitis, Gout, Burn• Blue – Cardiac Failure, Venous insuffiency• Black – Necrosis, Ischaemia, Emboli,

Bruise, Melanoma, Henna, Dye

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

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

Neurologic Assessment

• Sensory Neuropathy• Monofilament test buckles @10g• Vibration 128 Hz tuning fork• Temperature• Light Touch• Pain• Eyes closed, non-touch

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

Investigations

• Laboratory• Radiological• Vascular• Neurological• Foot Pressures

Laboratory

• CBC• RFT• LFT• RBS, HbA1C• Lipid Profile• CRP• Wound Cultures• Blood and Urine Cultures

Radiological

• Plain Films• Osteomyelitis• Fractures• Dislocations• Charcot foot• Foreign Body• Gas• CT • Technetium bone scan – early detection• MRI – Soft tissue

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

Neurological

• Neurothesiometer• Varying vibratory stimulus

Foot Pressures

• Plantar pressure measurement devices• Ink and paper

Classification

• University of Texas Wound Classification System of Diabetic Foot Ulcers

• Wagner• Edmonds

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

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

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

Edmonds Classification

Exceptions to this classification include • Charcot’s foot• Neuropathic fractures• Painful neuropathy

Management

• Regular inspection and examination• Multidisciplinary team• Patient education• Assess risk of foot• Non ulcer pathology• Ulcers and related pathology

Patient Education

• Optimum Glycemic control• Management of co-morbid conditions• Stop Smoking• Warning signs

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

Non Ulcer Pathology

• Calluses & Nails – Podiatrist• Skin pathology• Foot deformities – Surgical / Orthopedic

consult

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

Ulcer Pathology

Ulcer Pathology

• Low Threshold for Referral• Stage 3 and above associated with poor

control

Conclusion

• Diabetic foot is a serious complication• Associated with poor control• Prevention requires vigilance and patient

education• Treated by a multidisciplinary team

Thank You

• Questions?

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