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Medical Evaluation and Treatment A. Vascular disease a. Macroangiopathy & mikroangiopathy

Diabetic Clinical More common Younger patient More rapid 2:1 Multisegmental Involved Nondiabetic Less common Older patient Less Rapid 30 : 1 Single segment Not Involved

Male : Female Occlusion Vessels adjacent to occlusion Collaterals Lower extremities Vessels involved

Gangrene In-hospital mortality with amputation

Involved Both Tibials Peroneals Small vessel Arterioles Patchy areas of foot and toes Approximately 10 %

Usually normal Unilateral Aortic Iliac Femoral

Extensive Significantly less 2

b. Platelets & vascular diseases c. Peripheral vascular risk factor

- Age and duration : - Blood glucose control - Smoking - Genetic factor - Auto immune factor

d. Sign and symptoms of vascular insufficiency

Intermittent claudication Cold feet Nocturnal pain Rest pain Nocturnal and rest pain relieved with dependency Absent pulses Blanching on elevation Delayed venous filling after elevation Dependent rubor Athrophy of subcutaneous fathy tissues Shiny apperance of skin Loss of hair on foot and toes Thickened nails, often with fungus infection Gangrene

The five P5 of acute arterial occlusion Pain Pailor Paresthesias Pulselessness Paralysis

e. Vascular Laboratories : Doppler & ankle pressure (mm Hg) f. Arteriography

B. Diabetic Neuropathy
a. Sign and symptoms of DN Paresthesia, Hyperethesia, Hypoesthesia, Radicular pain, Loss of deep tendon reflexes, Loss of vibratory and position sense, Anhydrosis, Heavy callus formation over pressure points, Trophic ulcers, Infection complication trophic ulcers, Foot drop, Changes in shape of foot produced by the following: a. Mucle athrophy, b. Canges in bone and joints, Radiographics signs : a. Demineralization , b. Osteolysis, c. Charcots joint

Medical Management
1. 2. 3. 4. 5. 6. Education Exercise Diet Drugs Pancreas transplantation Surgery Saving the Diabetic Foot

II. Neuropathy and the Diabetic Foot

a. Conditions associared : b. Neurologic Evaluation 1. Poly neuropathy 1. Sensory 2. Mono Neuropathy 2. Strength ( Manual 3. Arthropathy muscle testing) 4. Auhidrosil 3. Autonomic System 5. Amyothrophy 4. Stretch Reflexs 6. Diabetic Cold Feet 7. Tarsal Turnel Syndrome 5. Nerve conduction ( N. Popliteal posterior studies and its branches) 8. Spontaneous Dislocation

III. Vascular disease

a. Arterial disease atherosclerotic vascular disease b. Arteriolar disease c. Capillary disease

IV. Non invasive evaluations of Peripheral arterial status : the physiological approach
1. 2. 3. 4. 5. Photo phethysmography Doppler Ultrasound Segmental Pressure Toe Pressure Waveform evaluations

V. Infection of the Diabetic Foot

The nails Paronychia Infection and vascular insufficiency Osteomyelities


VI. Surgical amputation & debridement

VII. Rehabilitation of the diabetic amputee

a. Preprothetic care / Pre op - Early mobilitation - Proper Nutrition - Care of the amputation stump


Rehabilitasi KD
Klasifikasi Wagner Derajat : - 0 : Lesi Terbuka kulit utuh deformitas kaki +/- I : Ulkus Sup + pada kulit - II : Ulkus menembus Td & Te - III : Ulkus dalam Osteomielitis +/- IV : Gangren jari kaki atau bag. Distal kaki, dengan atau tanpa selulitis - V : gangren seluruh kaki / tali bawah

Upaya Pencegahan
A. Primer 1. Penyuluhan kesehatan : - Umum - DM & Komplikasi - Kesehatan kaki 2.Status gizi yang baik & pengendalian DM 3. Pemeriksaan berkala - DM - Komplikasi 4. Prevensi & Proteksi kaki terhadap trauma 5. Pemeriksaan berkala kaki 6. Higiene personal termasuk kaki 7. Hilangkan faktor biomekanis yang memungkinkan terjadinya Ulkus

Sekunder 1. Aktif mencari kelainan kaki ( case finding ) pada penderita DM & yang potensial DM 2. tx & prevensi kelainan kaki lebih lanjut, tindakan bedah / podiatri 3. Cegah & turunkan kemungkinan komplikasi lebih lanjut 4. Cegah & kurangi / hilangkan kecacatan 5. Pengadaan fasilitas & SDM untuk perawatan kaki diabetik Tertier 1. Fasilitas pengelolaan max/ lengkap 2. terapi lebih lanjut & kontrol periodik - OP - Rehabilitasi Surgikal 14

Grade 0 : There is no open lesion. The skin is intact. There may be deformities such as claw toes. Depressed metatarsal heads. Hallux valgus with bunion, depressed longitudinal arch. Midfoot deformities from Charcot arthropathies, and other bony prominences about the midfoot and heel ( Fig. 11-5 ). Grade 1 : The skin lesion is that of a full-thickness loss but otherwise superficial in nature. Bony prominences may or may not be present ( Fig. 11-6 ) Grade 2 : The open lesion penetrates to tendon, bone, or joint. It thus represent a slightly deeper lesion than grade I ( Fig. 11-7 ) Grade 3 : The lesion has penetrated to a deeper area, and there is osteomyelitis, pyarthosis, plantar space abcess, or infection of tendon and tendon sheaths ( Fig. 11-8 ). Grade 4 : Gangrene is present in some portion of the toes or forefoot. There may be surrounding cellulitis, and the gangrene may be wet or dry ( Fig. 11-9 ) Grade 5 : gangrene involves the whole foot or such a percentage that no local procedures are possible, and a higher amputation is necessary ( Fig. 11-10 )