Introductory lecture on diabetic foot.

2. Hyderabad Chapter
Supervisor: Dr Abdul Ghani Rahimoon
Lecture 1:
Introduction to limbs for life program,
Types of Diabetes its early screening
and diagnostic criteria

3. Objective of this Program:
Save the limbs because limbs are life

4. Program Flow:
Disease burden
Complications
Foot ulcers
How to identify/ classify
Relations of DPNP and Foot Ulcer
Appropriate diagnostics and treatment
Offloading
Foot Wear

5. DISEASE
BURDEN
Diabetes a global crisis
537M Adults
Pakistan Ranked 3rd
High prevalence of
Diabetes
1 in 4 adult have diabetes
33 Million people have
diabetes
Prevalence
Undiagnosed
30%
26%
The IDF ranked Pakistan first
place for having the highest
comparative diabetes
prevalence rate in 2021 at
30.8%
The report noted that more
than a quarter (26.9%) of
adults living with diabetes in
Pakistan are undiagnosed.
73 million adults (Age Group
20-79) are living with diabetes
in the MENA Region.
27 million adults living with
diabetes in the MENA Region
are undiagnosed.
Diabetes is responsible for
796,000 deaths in the MENA
Region.

6. 50.9%
.
Diabetic Foot Ulcer
12-25%
Increased risk of
ulcer
6.6% - PAD cases in Pakistan
26% - P.N cases in Pakistan
.
Globally,
the prevalence of
Diabetic Foot Ulcer
is 13%
Younis, B.B., Shahid, A., Arshad, R. et al. Frequency of foot ulcers in people with type 2 diabetes, presenting to specialist diabetes clinic at a Tertiary Care Hospital, Lahore, Pakistan. BMC Endocr Disord 18, 53 (2018).
https://doi.org/10.1186/s12902-018-0282-y
https://www.researchgate.net/publication/344464402_Prevalence_of_Diabetic_Foot_Ulcer_in_Lahore_Pakistan_A_Cross_Sectional_Study?enrichId=rgreq-0f6feab40a24a02aebe976b36bb031e6-
XXX&enrichSource=Y292ZXJQYWdlOzM0NDQ2NDQwMjtBUzo5NDI4MjE4NTQ5NjE2NjRAMTYwMTc5NzY1NTgyMA%3D%3D&el=1_x_2&_esc=publicationCoverPdf
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7102459/#:~:text=According%20to%20a%20systematic%20review,13%25%20globally%20%5B13%5D.

7. Types of Diabetes, Screening and , Diagnostic criteria (CME Already Done)
Diabetes is a group of metabolic diseases characterized by hyperglycaemia resulting from defects in insulin secretion, insulin
action, or both. The chronic hyperglycaemia of diabetes is associated with long-term damage, dysfunction, and failure of
different organs, especially the eyes, kidneys, nerves, heart, and blood vessels.
Classification: Diabetes can be classified into four clinical categories:
1. Type1 diabetes – occurring due to b-cell destruction, usually leading to absolute insulin deficiency.
2. Type2 diabetes – occurring due to a progressive insulin secretory defect and insulin resistance.
3. Gestational diabetes mellitus (GDM) - diabetes diagnosed during pregnancy.
4. Other specific types of diabetes due to other causes, e.g., genetic defects in b-cell function, genetic defects in insulin action,
diseases of the exocrine pancreas (such as cystic fibrosis), and drug-or chemical-induced diabetes such as during the
treatment of HIV/AIDS or drug treatment after organ transplantation

9. Complications of Diabetes

10. Management of Type 1 and Type 2 Diabetes

11. Diabetic Foot- the Mechanism

12. Who can have an Ulcer-
People at Risk

14. Foot Before and After Re-vascularization

15. Neuropathy- A Double Edged Sword

16. Category Definition Score
Site
Forefoot
Midfoot and hindfoot
0
1
Ischemia
Pedal blood flow intact: at least one palpable pulse
Clinical evidence of reduced pedal flow
0
1
Neuropathy
Protective sensation intact
Protective sensation lost
0
1
Bacterial Infection
Infection None
Present
0
1
Area
Ulcer < 1cm2
Ulcer > 1cm2
0
1
Depth
Ulcer confined to skin and subcutaneous tissue
Ulcer reaching muscle, tendon or deeper
0
1
Total possible score 6
Diabetic Foot Ulcers (DFUs) Classification SINBAD System
Non Complicated DFUs
No Infection / Mild Infection
Score: 0-2 Score: 0-3
Complicated DFUs
Moderate Infection
Score: 4-5
Severe Complicated DFUs
Severe Infection
Score: 6

17. Diabetic foot Infection and Osteomyelitis
Osteomyelitis can affect any bone but most frequently the forefoot
(90%), followed by the midfoot (5%) and the hindfoot (5%).
amputation risk is significantly higher for hindfoot (50%), than
midfoot (18.5%) and forefoot (0.33%) Faglia E, Clerici G, Caminiti M, Curci V, Somalvico F. Influence of osteomyelitis locationinthe footof diabetic patientswithtranstibial amputation. Foot Ankle Int. 2013;34:222–227

18. Hammer Toe Claw Toe Flat feet
High Arched Feet Metatarsalgia Bunion Toe
Diabetic Foot Complications

19. Toe and Flow PAD
and Diabetes

20. Toe and Flow PAD and Diabetes

21. The Diabetic Foot Wounds-
Examination and Ulcer
Assessment
Hess, Cathy Thomas BSN, RN, CWCN Diabetic Foot Ulcer Assessment and
Management: Use of Classification Systems for Healing Progress, Advances
in Skin & Wound Care: December 2020 - Volume 33 - Issue 12 - p 670-671
doi: 10.1097/01.ASW.0000722268.83883.32

23. Wound Classification- Case Studies

24. Charcot Foot-Still a Dilemma

25. Foot Wear-For Protection and management of foot Ulcers
• The shoe should not be either too tight or too loose.
• Footwear should have Wide Toe box for free movement of
the toes.
• The inside of the shoe should be 1-2 cm longer than the foot.
• The internal width should equal the width of the widest part
of the foot, and the height should allow enough room for all
the toes
• Shoes should be made of soft leather, because they can
stretch
• Choose a cushioned sole over a thin, leather sole, because the
shock absorption is better.
• Tough but light-weight Outer soles absorb the plantar
pressure and limit motion of painful joints.
• Footwear requires lace or Velcro closures which will help to
adjust the size and deformities in the foot.
• Well-padded inner surface protects the foot from injury
due to fraction between foot and footwear.
• The footwear should always be purchase in the evening time
so that the swelling of the foot due to day long walking may
not lead to the tightness of the footwear.

26. 1. Heel Phase / Heel Strike: when we
walk, first of all the heel strikes on the
ground
2. Midstance Phase: the whole foot
including the middle portion strikes on
the ground and the feet bear the whole
of the body weight
3. Heel lift phase: The heel rises from the
ground and weight of the body is
shifted towards the forefoot.
4. Toe off phase: the whole foot rises
from the ground and body moves forward.
Offloading devices for management of Foot Ulcers

27. Anatomy of normal foot and ankle, foot arches, foot muscles, ligaments, fat pad, bursae,
ankle joint

28. Foot Examination- Important
Elements

29. Limbs for Life- Multan Chapter
Lecture No. Date
Introduction to the Learning Program
Types of Diabetes, Screening and , Diagnostic criteria 1
Complications of Diabetes 2
Management of Type 1 and Type 2 Diabetes 3
Diabetic Foot- the Mechanism 4
Who can have an Ulcer-People at Risk 5
Neuropathy- A double edged Sword 6
Diabetic foot Infection and Osteomyelitis 7
Toe and Flow PAD and Diabetes 8
Onsite Workshop- Identification of Neuropathy
The Diabetic Foot Wounds-Examination and Ulcer Assessment 9
Wound Classification- Case Studies 10
Charcot Foot-Still a Dilemma 11
Foot Wear-For Protection and management of foot Ulcers 12
Offloading devices for management of Foot Ulcers 13
Standard of Care-Diabetic Foot 14
Onsite Workshop- Diab. Foot Ulcer Classification, Charcot Foot
Anatomy of normal foot and ankle, foot arches, foot muscles, ligaments, fat pad, bursae, ankle
joint 15
Intervention and circulation of foot, X rays interpretation 16
Foot Examination- Important Elements 17
Onsite Workshop- Foot Wear, Classic Cases of PAD
Closing Ceremony
Course Outline: