Diabetic Foot

Definition

Infection, ulceration or destruction of deep tissues

associated with neurological abnormalities & various
degrees of peripheral vascular diseases in the lower limb.
 EPIDEMIOLOGY
• 40% - 60% of all non traumatic lower limb amputation
• Mortality following amputation 50-68% at 5 years

In Indonesia
- 17-23% are mortality related to ulcer and gangren
Etiology
Aetiology
 Examination of the Ulcer
• Size/depth/location?
• Colour/status of wound bed?
– Black (necrosis)
– Yellow, red, pink
• Bone exposed?
• Gangrene/necrotic
• Infection? Malodour? Local pain?
• Exudate? Production? Colour? Consistency?
• Wound edge (callus, maceration, erythrma,
oedema, undermining)
 Sign Ischaemia
• Claudication
– Pain leg muscle
– Exercise-induced
– Absent in people with diabetes
• Temperature difference between feet
Classification
 Assessment Monofilament for pressure sensation
(pinprick sense)

• Place a 10g nylon Semmes-Weinstein monofilament

at a right angle to the skin

• Test 4 plantar sites on the forefoot (great toe and the

base of 1st, 3rd and 5th metatarsals )

• Inability to perceive the 10g of force applied by the

monofilament is associated with large fibre
neuropathy (sensitivity of 66 to 91%)
 Assessment Peripheral Vascular Disease (PVD)
Check the blood flow
• History : claudication
• Examination: Palpate the foot for temperature (cool in PVD); palpate the
dorsalis pedis pulse and, if absent, the posterior tibial pulse.

Palpation of the dorsalis pedis pulse Palpation of the posterior tibial pulse
Assessment Investigations

 detect the dorsalis pedis pulse using a small hand-

held doppler.

 The ankle brachial pressure index (ABPI)

ABPI is usually >1 but in the presence of peripheral

vascular disease is <1. Normal ABPI effectively
excludes significant arterial disease in >90% of
limbs.

Doppler being used to detect

the dorsalis pedis pulse
 Holistic Approach

Optimal diabetes control

Effective local wound care

Infection control

Pressure relieving strategies

Restoringpulsatileblood flow
 Management

Deformities should be accommodated in properly

fitting footwear.

Callus: Is the most important pre-ulcerative lesion in

this stage. It remove by a scalpel.

Dry skin and fissure: treat with an emolient (E45 or

calmurid cream), reduce fissure margins with
scalpel

Callus removal
Management Peripheral Arterial Disease (PAD)

If PAD is evident:
• address cardiovascular risk
factors
– smoking
– dyslipidaemia
– hypertension
• treat with oral aspirin 75mg
Management Ulcers due to Ischaemia

Medical: reduce cardiovascular risk factors

Surgical: revascularisation to achieve timely and

durable wound healing is sometimes necessary.

Open bypass surgery -- for those patients who do

not have an endovascular option.

Ischaemic necrosis of a
toe and an extensive
plantar ulcer
Management Ulcers due to Neuropathy
Key treatment to redistribute plantar
pressure

Air cast (walking brace)

The cast is lined with 4 air cells
which can be inflated with a hand
pump to ensure a close fit.

An air cast
Scotch cast boot
A simple, removable boot made of
stockinette, soffban bandage, felt and
fibreglass tape.

A scotch cast boot

 Management Wound Debridement

Debridement is the removal of necrotic and dead

tissue in order to enhance healing.
Debridement is undertaken to:
• Remove callus
• Assess the true dimension of the ulcer
• Drain exudate and remove dead tissue to render
infection less likely
• Take a deep swab for culture Forcep and a scalpel is the
usual technique by cutting
• Encourage healing and restore a chronic wound to away of all slough and non-
an acute wound viable tissue.
Management Wound Debridement using maggots (larvae
therapy)
The larvae of the green bottle fly

Maggots produce a mixture of proteolytic enzymes

 breakdown slough and necrotic tissue.

they also ingest and kill bacteria including antibiotic

resistant strains.
 Management New Developments
• Hyperbaric oxygen therapy: Poor tissue oxygenation with
diabetic microangiopathy reduces wound healing. -- faster wound
healing,

• Growth factor therapy: PDGF, applied as a gel ( enhance

granulation tissue formation and facilitate epithelialisation) .

• Bioengineered human dermis transplantation: generate

growth factors, cytokines, matrix proteins and
glycosaminoglycan, thus aiding the healing process.
Management Infected Ulcers - Antibiotics

Oral antibiotics Perenteral antibiotics

Penicillin V OR co-amoxiclav Benzylpenicillin +/-

+/-

•Flucloxacillin •Flucloxacillin
•Ciprofloxacillin •Imipenem-cilastin
•Cephalexin •Ampicillin-sulbactam
•clindamycin •Cefuroxime
•Metronidazole ( for anaerobes )

For mild infections, 7-10 day course is usually sufficient. Severe infections
may need up to 2-3 weeks of treatment.
Management Amputation

When ulceration is not healing/ infection worsening

Signs include:
 Extensive tissue loss
 Unreconstructable ischaemia
 Failed revascularisation
 Charcot’s of ankle with instability
Management Pain

Drugs;
Simple analgesics; e.g. aspirin, paracetamol, and mild opiates
such as codeine
Trycyclic antidepressants; e.g imipramine, amitriptyline.
Anticonvulsants; e.g carbamazepine, valproate, phenytoin
Capsaicin (topical analgesic)
THANK YOU