Diabetic foot Introduction Approximately 10% of diabetic admissions to hospital are with foot problems.

The severity of diabetic foot disease is not related to the severity of the diabetes but rather to the adequacy of blood sugar control. Pathology One-third of diabetic foot ulcerations are neuropathic One-third are ischaemic One-third are mixed in nature Neuropathy Symmetrical distal polyneuropathy involving motor, sensory and autonomic nerves. Investigations For nerve function Biothesiometer. Measures vibration perception threshold. The calculated standard deviation score evaluates the risk of ulceration SemmesWeinstein hairs: nylon monofilaments of the same length but different diameters. If the 5.07 hair can be felt, the patient has protective sensation Nerve conduction studies. Can give spurious results if some fibres are conducting and others

are not For vascular status Doppler ultrasound Ankle/brachial index. Normal value is 1 and a value <1 indicates peripheral vascular disease. Treat with caution in diabetics as calcification of the arteries makes them relatively incompressible and gives spurious results Angiography For infection Culture and stain. There is usually a polymicrobial colonization of foot ulcers. Most common organisms are Staphylococcus aureus, Escherichia coli, Streptococci and anaerobes. Give antibiotics only if there is clinical evidence of cellulitis, abscess or evidence of osteomyelitis White cell count, ESR Plain radiographs looking for osteomyelitis Bone scan or labelled white cell scan Management Eliminate infection Remove infected bone Drain abscesses Neuropathic ulcers These are healed by limitation of causative

mechanical forces. Strict bed rest is expensive and has a risk of complications. Advise non-weightbearing on crutches and a total contact plaster padding, a rocker for walking, and a hole cut where the ulcer is. Ischaemic ulcers These are made worse by total contact plasters. Arteriography is helpful to determine whether angioplasty or bypass surgery is possible. Ulcers of mixed aetiology Usually there are more ulcers of one type than of the other. If it does not bleed, it is likely to be ischaemic; if it does, neuropathic. Aim for prevention of further ulceration through good diabetic control and well fitting shoes. Surgery Debridement of infected ulcers, drainage of abscesses and excision of infected bone Revascularization of ischaemic foot Amputation for gangrenecast. Apply a below-knee plaster cast with minimal

Oral questions Discuss the role of amputation in the diabetic foot Describe how to salvage the foot at risk