Diabetic foot lecture summary revision for fourth year medical students at Ajdabya University , school of medicine

1. Ajdabya University – Medical College
General Surgery Department
Dr. Abdulgadir Almograby , MD
Diabetic foot overview
)Revision(

2. Objectives
1-Definition of diabetic foot
2-Epidemiology & significance of the problem
3-Pathophysiology of diabetic foot
4-Risk factors of diabetic foot
5-Clinical features of diabetic foot
6-Management of diabetic foot
7-Prevention of diabetic foot complications
(4Dos and 4 Don't(

3. Definition
1-Definition of diabetic foot
Diabetic foot is a spectrum of foot disorders
occurring in diabetics ranging from foot
ulceration to gangrene as a result of ischemia ,
neuropathy or both and -/+ an infection [1[
DF= is the foot of diabetic patient

4. Diabetic foot:
Infection
Ulceration
Charcot’s foot
Gangrene
Ischemia
Neuropathy
Neuro-ischemia
Infection/Sepsis
Definition
Occurring
in Diabetic
patients

5. Epidemiology
Rule of 15% *:
15%of people with diabetes develop ulcers
15%of ulcers develop osteomyelitis
15%of ulcers result in amputation
*Armstrong, David G. and Lavery, Lawrence A. (2005(.
Clinical Care of the Diabetic Foot. American Diabetes Association. ISBN-10:
1580402232

6. Cost of diabetic foot
20%of All hospital admissions of diabetic
patients are due to foot problems
]1[Average hospital stay = 16 weeks.
Length of hospital stay for people with diabetic foot
problems is 13 days longer than for people with
diabetes who do not have foot problems, after
adjusting for age, sex, ethnicity, deprivation, elective or
emergency admission, and surgical or non-surgical
*specialty. *Foot care for people with diabetes in the NHS
in England: The economic case for change
March 2012

7. Cost of diabetic foot
USA
14I IDF Diabetes Atlas I Sixth edition

8. Ischemia Neuropathy Infection
Etiology of DF
Diabetic
Sensory
Neuropathy
NO pain
sensation
Foot > Vulnerable
to Repetitive
Unnoticed
Trauma
Ulceration
7Folds
Risk

9. Neuropathic vs. Ischemic DFUs
Variable %35Neuropathic ulcer %15Ischemic ulcer
1-Pain
2-Pulse
3-Sensation
4-Local Temp
5-Site
6-Claudication
7-Treatment
Painless
Normal arterial pulses
Loss of sensation
Warm foot
Plantar ulceration
No intermittent claudication
Treated by local measures
Painful
Reduced or absent pulses
Variable sensory findings
May be cold foot
Toe ulceration
Intermittent claudication
Requires reconstructive
)+/-Revascularization )
surgery
]1[

10. PERIPHERAL NEUROPATHY
Neuropathy Features
Sensory Neuropathy Loss of protective sensations
More vulnerable to physical,
chemical and thermal trauma
Motor Neuropathy Foot deformities (such as
hammer toes and claw foot), which
may result in abnormal
pressures over bony prominences
Autonomic Neuropathy
Fissures, cracking and callus dry
skin,
Bounding dorsal pulses.
]7[Boulton AJ, Armstrong DG, Albert SF, et al. Comprehensive foot examination
and risk assessment. Diabetes Care 2008; 31: 1679-85.

11. Diabetic Sensory
Neuropathy
Loss of protective sensation is a major
component of nearly all DFUs . [4,5].
It is associated with a seven–fold increase in risk
of ulceration.
Patients with a loss of sensation will have
decreased awareness of pain and other
symptoms of ulceration and infection. [6]

12. Diabetic Sensory
Neuropathy
A-“Glove and Stocking” distribution
B- Paresthesia
C- Anesthesia

13. TESTING FOR LOSS OF SENSATION:
Two simple and effective tests for peripheral
neuropathy are commonly used:
1-10g (Semmes-Weinstein) monofilament
*2-Standard 128Hz tuning fork.
Diabetic Sensory
Neuropathy Examination
Using a monofilament to test for neuropathy *BEST PRACTICE GUIDELINES: WOUND
MANAGEMENT IN
DIABETIC FOOT ULCERS

14. Diabetic Motor
Neuropathy

15. Diabetic Autonomic
Neuropathy
Loss of Sympathetic tone = VD

16. Diabetic foot Ischemia
DIABETIC FOOT DISORDERS VOLUME 45, NUMBER 5, SEPTEMBER/OCTOBER 2006 S–5

17. Diabetic foot Ischemia features
Asymptomatic
Intermittent claudications
Impotence
Symptoms & signs of ischemia:
Pain , coldness ,pallor, Rest pain , Absent
pulsations
Ulceration[painful ], Sepsis [Fung-Bact.] –
Gangrene. : tissue destruction ]1[

18. Diabetic foot infection features
Fever, chills ,rigors , tachycardia, swelling,
discharge , loss or decr. Function ,less pain
Inter-digital(web) fungal infection (maceration(
Bacterial infection =( cellulitis –localized or
spreading ) , tissue necrosis , Abscess ,
Osteomyelitis , +/_ Gangrene . [1]

19. Diabetic foot infection features

20. Bacteriology =Polymicrobial
DIABETIC FOOT DISORDERS VOLUME 45, NUMBER 5, SEPTEMBER/OCTOBER 2006 S–31

21. Non-invasive
1-Blood glucose, HbA1c
2-RFT,Lipid profile
3-ABI, Segmental pressure,
Digital pressure
NB-[ ABI may be falsely
Elevated due to medial
sclerosis].
4-X-rays of foot
Invasive
Angiography:
Conventional , CTA , MRA.
Investigations of DF
]1[

22. Management of Diabetic foot
Neuropathic Diabetic foot
1-Control infection:
Antibiotics against Both
Areobes & Anaerobes
2-Drain & Debride:
Wide local excision of
necrotic tissues
Ischemic Diabetic foot
1-Formal assessment Of
the vascular tree
with Angiography
2-Revascularization of the
foot [By Angioplasty or
bypass surgery]
3-After restoration of
blood supply = treat as
neuropathic disease.
]1[

23. Classification systems for DFUs
Wagner Classification System

24. Prevention
The old adage that:
)prevention is better than cure(
is better illustrated in the management of the
diabetic foot than anywhere else in
medicine[1[.

25. Prevention
4Dos 4Don't
Do
1-Carefully wash and dry feet daily
2-Inspect feet for injury daily
3-Take meticulous care of toenails
4-Apply antifungal powder to feet
daily
Don't
1-Walk barefoot
2-Wear ill-fitting shoes
3-Use a hot-water
bottle
4-Ignore any foot injury
[1[

26. Together To Make - Almgareaf
Ajdabia Hospital as Teaching
Hospital = Campaign