Transcript Slide 1
Diabetic Foot An Overview
Foot team
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Prof.Mamdouh El Nahas Prof.Hanan Gawish Dr. Manal Tarshoby Dr.Omnia State
World Diabetes Day 2005 Diabetes and Foot Care Put Feet First Prevent Amputations
2005: a Year-long Campaign
Campaign Objectives
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Inform people of the extent of diabetic foot problems worldwide.
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Persuade people that action is both possible and affordable.
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Warn people of the consequences of not taking action.
FOOT FACTS (1)
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Every 30 seconds a leg is lost to diabetes somewhere in the world.
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Up to 70% of all leg amputations happen to people with diabetes.
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DF problems are the commonest cause of hospital admission. (by us?)
FOOT FACTS (2)
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Most amputations begin with a foot ulcer.
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One in every six people with diabetes will have a foot ulcer during their lifetime.
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Good News
Up to 85% of amputations can be avoided.
Egypt Representative Mansoura University
Prof.Mamdouh El Nahas.
Dr.Hanan Gawish Dr. Manal Tarshoby Dr.Omnia Stat
Levels of foot management
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Level 1 General practitioner, diabetic nurse and podiatrist
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Level 2 Diabetologist, surgeon (general and/or vascular and/or orthopedic), diabetic nurse and podiatrist
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Level 3 Specialized foot center
Value of Podiatric Care 14 12 10 8 6 4 2 0 84 85 Year 86 87
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KINGS COLLEGE HOSPITAL.
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1984 establishment of DIABETIC FOOT CLINIC.
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Amputation decreased 50% in 3 years.
Diabetic Foot
Diabetic Foot Disease
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Ischaemia Neuropathy Infection Structural deformity Ulcer Amputation
Five cornerstones of the management of the diabetic foot
Regular inspection and examination of the foot.
Identification of the foot at risk.
Education of patient, family and healthcare providers.
Appropriate footwear.
Treatment of non ulcerative pathology
Five cornerstones of the management of the diabetic foot
Regular inspection and examination of the foot.
Identification of the foot at risk.
Education of patient, family and healthcare providers.
Appropriate footwear.
Treatment of non ulcerative pathology
Regular inspection and examination of the foot
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All diabetic patients should be examined at first presentation then at least once a year Patients with risk factors should be examined every 1-6 months Absent symptoms does not mean that the feet are healthy Examine the patient on lying down and standing up Shoe and socks should be inspected
History
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Previous ulcer , amputation Previous foot education Bare-foot walking Poor access to healthcare Smokimg , alcohol Nephropathy,Retinopathy Hypertension Ischemic heart disease
Foot examination 1.
Nails Thick too long ingrown fungal infection wrongly cut nails
Foot Examination 2.
Foot deformity:
Foot Examination 2.
Foot deformity:
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Toe deformity
Hammer toe Claw toe
Toe Deformity:– Hammer Toe
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Increased pressure on 2 nd metatarsal head Increased pressure on prox. IPJ Increased pressure on distal IPJ Increased pressure on apex Increased pressure on nail fold
Foot Examination 2.
Foot deformity:
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Toe deformity Forefoot deformity Hallux valgus Hallux rigidus
Hallux Valgus
Hallux Rigidus
Osteoarthritic Degeneration 1 st MTP Joint Limitation of Dorsiflexion Overloading 2 nd MTP Joint / 1 st IPJoint
Foot Examination
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2.
Foot deformity: Toe deformity Forefoot deformity Wholefoot Deformities
Pes Cavus - High arched foot Pes Planus - Flat foot Charcot foot
Diagnosis of Acute Charcot
Painless
Redness, swelling, and more than 2°C skin temperature difference when compared with the contralateral foot.
Dorsalis pedis pulses are often bounding.
The patient is afebrile unless a systemic infection is present.
Foot Examination 2.
Foot deformity: Toe deformity Forefoot deformity Whole foot Deformities Prominent metatarsal heads
Foot Examination 3.
Skin condition: Callus Bunions Redness Warmth Fissure Dryness Swelling Maceration Fungal infection
Callus
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Presence of callus is a significant marker for the development of foot ulceration The hyperkeratosis is a result of hypertrophy under the influence of intermittent compression .
the callus is either a reaction to abnormal pressure or an abnormality of the area to handle normal pressure.
Tenia Pedis
Foot Examination 4.
Vascular assessment:
History
Intermitent claudication Rest pain
Colour of the skin Temperature gradient
Foot Examination 4.
Vascular assessment:
Pedal pulse
Dorsalis pedis Posterior tibial
Foot Examination 4.
Vascular assessment:
Pedal pulse
Dorsalis pedis Posterior tibial
Ankle Brachial Pressure Index
Foot Examination 5.
Neurological assessment:
Neurologic assessment
Temperature Vibration Sense Pressure Sense Light Touch Proprioception Reflexes
Neurologic assessment
Neurologic assessment
Temperature Vibration Sense Pressure Sense Light Touch Proprioception (Romberg’s Sign) Superficial Pain Reflexes
TEMPERATURE TESTING
Two test tubes, hot/cold.
Therm-tip Subjective, crude tests
Neurologic assessment
Temperature Vibration Sense Pressure Sense Light Touch Proprioception Superficial Pain Reflexes
VIBRATION SENSE
NEUROTHESIOMETER
Neurologic assessment
Temperature Vibration Sense Pressure Sense Light Touch Proprioception Superficial Pain Reflexes
MONOFILAMENTS
10 gm Sites tested Technique Significance
Neurologic assessment
Temeprature Vibration Sense Pressure Sense Light Touch Proprioception Superficial Pain Reflexes
LIGHT TOUCH TEST
Neurologic assessment
Temperature Vibration Sense Pressure Sense Light Touch Proprioception Superficial Pain Reflexes
PROPRIOCEPTION TEST
Tested by dorsiflexing and plantarflexing the hallux. Can the patient determine the position of the hallux?
Neurologic assessment
Temperature Vibration Sense Pressure Sense Light Touch Proprioception Superficial Pain Reflexes
SUPERFICIAL PAIN TEST
Neurologic assessment
Temperature Vibration Sense Pressure Sense Light Touch Proprioception Superficial Pain Reflexes
ANKLE REFLEX
Five cornerstones of the management of the diabetic foot
Regular inspection and examination of the foot.
Identification of the foot at risk.
Education of patient, family and healthcare providers.
Appropriate footwear.
Treatment of non ulcerative pathology
Risk Categorization
Category Risk categorization system Risk profile Check up frequency 0 no sensory neuropathy once a year 1 sensory neuropathy once every 6 months 2 sensory neuropathy and signs of peripheral vascular disease and/or foot deformities.
once every 3 months 3 previous ulcer once every month
Five cornerstones of the management of the diabetic foot
Regular inspection and examination of the foot.
Identification of the foot at risk.
Education of patient, family and healthcare providers.
Appropriate footwear.
Treatment of non ulcerative pathology
Five cornerstones of the management of the diabetic foot
Regular inspection and examination of the foot.
Identification of the foot at risk.
Education of patient, family and healthcare providers.
Appropriate footwear.
Treatment of non ulcerative pathology
Five cornerstones of the management of the diabetic foot
Regular inspection and examination of the foot.
Identification of the foot at risk.
Education of patient, family and healthcare providers.
Appropriate footwear.
Treatment of non ulcerative pathology
What is going on??
Foot care team •
??Podiatrists
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Orthotists.
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Diabetologists.
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Vascular Surgeon.
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Educators.
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Microbiologist.
Ulcer assessment 1.
Establish the ulcer's etiology 2.
Measure its size 3.
Establish its depth and involvement of deep structures 4.
Examine it for purulent exudates, necrosis, sinus tracts, and odor 5.
Assess the surrounding tissue for signs of edema, cellulitis, abscess, and fluctuation 6.
Exclude systemic infection 7.
Perform a vascular evaluation. 8.
The ability to gently probe through the ulcer to bone has been shown to be highly predictive of osteomyelitis.
( should be recorded at base line and every subsequent visits ± digital photo)
• A multidisciplinary approach
providing debridement, meticulous wound care, adequate vascular supply, metabolic control, antimicrobial treatment and relief of pressure (offloading) is essential in the treatment of foot ulcer.
Dressing
Do not put anything on the ulcer that you wouldn’t put in your eye!!
No evidence from large trials
Debridement Sharp Larval Enzymatic (Lytic) Indication & Contraindication??
Offloading
Offlaoding
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What is meant by offloading
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Different offloading modalities
Key Message
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Of all late complications of diabetes, foot problems are the most easily detectable and easily preventable.
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Relatively simple interventions can reduce amputations by 50 - 80%.
(Bakker et al 1994).
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Strategies aimed at preventing foot ulcers are cost effective and cost saving.
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Only champions willing to act are needed.
Don’t Forget to take your copy!