2. DEFINITION
According to WHO Diabetic Foot defined
as pathologic consequences, including
infection , ulceration and/or destruction of
deep tissues associated with neurologic
abnormalities, various degrees of
peripheral vascular disease, and/or
metabolic complications of diabetes in the
lower limb”.
3. INTRODUCTION TO DM
Diabetes mellitus is a group of metabolic diseases characterized by
hyperglycemia resulting from defects in insulin secretion, insulin action, or
both.
The chronic hyperglycemia of diabetes is associated with long-term
damage, dysfunction, and failure of various organs, especially the eyes,
kidneys, nerves, heart, and blood vessels.
Diabetic foot is defined as any foot pathology that results directly from
diabetes or its long term complications
4. WHO CLINICAL CLASSIFICATION OF
DIABETES MELLITUS
1.Diabetes mellitus(DM)
Type 1 or Insulin-dependent diabetes mellitus
Type 2 or Non-insulin dependent diabetes mellitus
Malnutrition related diabetes mellitus(MRDM)
Other types
(secondary to pancreatic, hormonal , drug-induced, genetic and other)
2.Impaired glucose tolerance(IGT)
3.Gestational diabetes mellitus(GDM)
4
5. TYPES OF DIABETES
Type 1 diabetes Type 2 diabetes Gestational diabetes
• Lack of insulin
• Autoimmune
• Usually children
• Insulin resistance
• Lifestyle factors
• Usually adults
• Insulin resistance
• During pregnancy
• Risks to mother and
child
7. MAGNITUDE OF DM
Globally 422 million people have diabetes
90% Type II
The greatest number of people with diabetes are between 40 and
59 years of age
Global prevalence-9.1%
Asians shows more vulnerability
The prevalence of Diabetes in India is 8.6%.
India is set to become the diabetes capital of the world with a
projected 109 million individuals with diabetes by 2035.
Currently 63 million suffered from DM.
80% of diabetic death from lower and middle class .
Every six seconds a person dies from diabetes
1.5million die each year due to diabetes related causes.
India ranks second (after China) with more than 66.8
million diabetics in the age group of 20-70.
8. BURDEN OF DF
Diabetic Foot (DF) is one of the most common complications for admissions imposing
tremendous medical and financial burden on our healthcare system.
The life time risk of a person with diabetes having a foot ulcer could be as high as 25% and is the
Commonest reason for hospitalization of diabetic patients (about 30%) .and they absorbs about
20% of the total health-care costs, more than all other diabetic complications.
The prevalence of foot ulcer in diabetics attending a center managing diabetic foot (both indoor
and outdoor setup) in India is 3%.
Foot ulcers among outpatient and inpatient diabetics attending hospitals in rural India was found
to be 10.4%.
Peripheral vascular disease (PVD) occurs in about 3.2% diabetics below 50 years of age
and rises to 55% in those above 80 years of age.
15% of those with diabetes for a decade suffer from diabetic foot, where as it increases to almost
50% by another decade.
9. MORBIDITY AND MORTALITY OF DF
• Approximately, 85% of non-traumatic lower limb amputations are seen in patients
with prior history of diabetic foot ulcer.
• Each year, more than 1 million people with diabetes lose at least a part of their leg
due to diabetic foot. It shows that every 20 seconds a limb or its part is lost in the world
somewhere.
• 45,000 legs are amputated every year in India.
• The vast majority (75%) of these are probably preventable because the amputation often
results from an infected neuropathic foot.
• More than half of all foot ulcers become infected, requiring hospitalization, while 20% of infections
result in amputation.
• After a major amputation, 50% of people will have the other limb amputated within two years time.
• People with a history of diabetic foot ulcer have a 40% greater 10-year death rate
than people with diabetes alone.
10. Bibilography:
WORLD HEALTH ORGANIZATION
DIABETIC FOOT SOCIETY OF INDIA
INTERNATIONAL DIABETES FEDERATION
AMERICAN DIABETES ASSOCIATION
11. RISK FACTORS
DIABETES MELLITUS
Sedentary lifestyle
Diet
Dietary fiber
Malnutrition
Alcohol
Viral infections
Chemical agents
Stress
Socioeconomic status
Urbanization
DIABETIC FOOT
Male sex
DM > 10 years duration
Peripheral neuropathy
Abnormal foot structure
Peripheral arterial disease
Evidence of ischemia in foot ( ABI < 0.9)
Callus
Inappropriate footwear
Smoking
H/O previous ulceration / amputation
Poor glycemic control (HbA1c > 7%)
12. CLINICAL FEATURE
DIABETES MELLITUS
Image
DIABETIC FOOT
Pain in the foot
Ulceration
Hair loss
Dry skin
Absence of sensation
Absence of pulsations:-Posterior tibial
and dorsalis pedis arteries
Chronic Osteomyelitis
Abscess formation
Gangrene
13. PATHOPHYSIOLOGY
Factors leading to development of diabetic foot:
Diabetic polyneuropathy – loss of sensation
Diabetic macroangiopathy – peripheral arterial occlusive disease
Diabetic microangiopathy – thickening of basement membranes
Diabetic osteoathropathy – abnormal foot biomechanics
Vascular disease
Reduced resistance to infection
Delayed wound healing
Reduced rate of collateral vessel formation
14.
15. PERIPHERAL NEUROPATHY
• IT COMMONLY MENIFESTS AFTER ABOUT 10 YEARS OF LIFE
• NEUROPATHY CAN BE DISTAL AND DIFFUSE WITH A STROCKING TYPE OF DISTRIBUTION.
3 TYPE OF NEUROPATHY
I. Sensory neuropathy
II. Motor neuropathy
III. Vegetatative neuropathy
SENSORY NEUROPATHY
Predominates
Large fibres - tactile and deep sensitivity
Small fibres - pain and heat sensitivity
Nerve damage is due to formation of sorbitol from the sugar.
SORBITOL causes demyelination of nerve fibres.
16. MOTOR NEUROPATHY
Weakness and atrophy of the intrinsic
muscles of the foot-clawtoe
Loss of joint mobility
Secondarily, it contributes to loss of
joint mobility, which is also due to
conjunctive tissue glycosylation inducing
fibrosis of the joint, soft tissue and skin
VEGETATIVE NEUROPATHY
Induces skin dryness with crevasses and
fissures providing entry points for
infection
Hyperkeratosis in reaction to
hyperpressure
Opens arteriovenous shunts and
induces deregulation of capillary flow
The neuropathic foot is hot, with
frequent edema and dilated dorsal
veins
18. Microangiopathy
Thickening of the capillary
membrane, induce
abnormal exchange and
aggravate tissue ischemia
Induces chronic ischemia,
which is an aggravating
factor in foot lesions
The foot is cold and the skin
becomes thin and shiny
19. The Lewis Triple Flare Response is absent
in diabetic patients affecting wound
healing
LEWIS TRIPLE FLARE RESPONSE
20. Autonomic Neuropathy
Regulates sweating and perfusion to
the limb
Loss of autonomic control inhibits
thermoregulatory function and
sweating
Result is dry, scaly and stiff skin that is
prone to cracking and allows a portal
of entry for bacteria
31. TYPICAL FEATURES OF DIABETIC
FOOT ULCER ACCORDING TO
ETIOLOGY
Feature Neuropathic Ischemic Neuroischemic
Sensation Sensory loss
Painless
Painful Degree of sensory loss and
painless
Callus/necrosis Callus present and often thick Necrosis common Minimal callus
Prone to necrosis
Wound bed Pink and granulating,
surrounded by callus
Pale and sloughy with poor
granulation
Poor granulation
Foot temperature and pulses Warm with pulses present Cool with absent pulses Cool with absent pulses
Other Dry skin and fissuring Delayed healing High risk of infection
Typical location Weight bearing areas of the
foot such as metatarsal heads,
the heel and over the dorsum of
clawed toes
Tips of toes, nail edges and
between the toes and lateral
borders of the foot
Margins of the foot and toes
32. A 55 yrs old married hindu female patient named Jayaben Lakshman Pawar residing at
Umargao,Maharashtra belongs to lower socioeconomical status was admitted on 16/8/2016 at Civil
Hospital, Valsad with chief complain of Swelling over the foot and small blackish area over left
second toe due to cat bites on her left second toe. And she developed Fever after a 4 days of
admission.
CASE
33. ODP:
Patient was relatively well before 2 aug 2016. On 2 aug 2016 cat bites on her second
toe.
On same day she visited near by government hospital with pain and swelling over the
left foot .
She was treated for primary care and refered to Civil hospital-valsad for further
treatment.
After that she develop sever pain & blackening area over the left second toe. So she
visited valsad civil hospital on 16/8/2016 and she was admitted .
At the time of admission there was blackening of second toe present after that ulcer
developed from second toe and surroundings area which gradually increase in size
spread to following area:
whole dorsal surface of foot
anterior : 6 inch above from ankle
Posterior : 7.5 inch above from ankle
Medially : 3.5 inch above from ankle
Laterally : 8 inch above from ankle
After 4 days of admission she developed a mild Fever which was subsides after a week
.And again she developed a fever 3 days ago.
34. NEGATIVE HISTORY
• No other ulcer on the body
• No Trauma Previously
• No Discharge
• No Bleeding
PAST HISTORY
• Known case of DM since 5 yrs
• TB 10 yrs ago ( treated)
• No jaundice
• No Hypertension
• No Blood Transfusion
• No major surgeries
FAMILY HISTORY
• Nothing significant
35. PERSONAL HISTORY
Diet: mix
Appetite : increased
Sleep : adequate
Bowel habit : Once in 3 days
Bladder : 10-12 times a day
Addiction : NO
Allergy : No
Drug : Antidiabetic treatment
36. GENERAL EXAMINATION
Patient was conscious ,cooperative and well oriented to time, place ,person .
Built: Well
Nourishment : Well
Pallor : Mild
Icterus : absent
Cyanosis : absent
Clubbing : absent
Odema : absent
Inguinal lymphadenopathy
No dilated veins or scars
37. VITALS
Temperature : Normal by palpatory method
Pulse : 86 bpm with normal rate ,rhythm , force, tension ,volume and condition of arterial
wall in rt radial artery in supine position.
Respiratory rate : 18 Breath /min by inspection
BP : 126-84 mm hg in supine position in right brachial artery by auscultatory method.
38. LOCAL EXAMINATION
INSPECTION
SIze :
Approximately
whole dorsal surface of foot
anterior : 6 inch above from ankle
Posterior : 7.5 inch above from ankle
Medially : 3.5 inch above from ankle
Laterally : 8 inch above from ankle
Shape : Large irregular
Number : single
Position: over the dorsal surface and leg
Edge : slopped edges , slight red tissue
Margin : irregular
Floor : Dry, slough , necrotic tissue with visible muscle mass. No granulation tissue seen.
Base : ulcer reside on muscle mass
Discharge : No
Surrounding area : Flaky & thin skin , loss of hair
39.
40. PALPATION
All inspectory findings are confirmed.
Tenderness on touching
Edge : Slopping , Dry and solid
Margin : Irregular , Dry and solid
Base: Slight induration on pressing
Depth : 7 to 8 mm
No bleeding on touch
Relation with deeper structure : fixed to underlying structure.
Temperature : cold on ulcer and toe
Surrounding Skin : increased temperature
42. TREATMENT HISTORY
DRESSING EVERYDAY
Ray’s Amputation OF LEFT 2ND TOE
ANTIBIOTIC
• Ceftriaxone
• Culture sensitivity test after that specific antibiotic
ANTIDIABETIC
• Insulin
OTHER DRUG
• Inj. Diclo
• Inj. Rantec
• Inj. Emset
44. Assessment of a Diabetic Foot Ulcer
Examination of the ulcer
Blood sugar examination
Testing for loss of sensation.
10g Semmes-Weinstein monofilament and standard 128Hz tuning fork are simple
and effective screening tool
Testing for vascular status. This can be done by palpation of the peripheral pulses,
Duplex ultrasound, Angiography
Identifying infection and taking culture
Full blood count, electrolytes, inflammatory markers,HbA1C (ESR, CRP)
Inspecting feet for deformities
Assessing bone involvement (Using XRAY or MRI or CT-SCAN)
45.
46. 128 Hz tuning fork - The tuning
fork explores vibratory
sensitivity on the dorsal side of
the 1st metatarsal
47. Assessment Infected Ulcers
Assessing foot ulcers for the presence of infection is
vital. All open wounds are likely to get colonised with
microorganisms, such as Staphylococcus aureus , and
not necessarily infected. Therefore, the presence of
infection needs to be defined clinically rather than
microbiologically.
An infected ulcer
Signs suggesting infection
purulent secretions
presence of friable tissue
undermined edges
foul odour
48. ASSESSMENT STRUCTURAL
ABNORMALITIES AND DEFORMITIES
Structural abnormalities and deformities lead to bony
prominences which are associated with high mechanical
pressure on the overlying skin.
This results in ulceration, particularly in the absence of a
protective pain sensation and when shoes are unsuitable.
Ideally, the deformity should be recognised early and
accommodated in properly fitting shoes before ulceration
occurs.
Common abnormalities / deformities include:
i. Callus
ii. Bunion
iii. Hammer toes
iv. Claw toes
v. Charcot foot
vi. Nail deformities
Callus on plantar surface
Bunion on the medial border of the foot
49. Claw toes Charcot footNail deformity
ASSESSMENT - SOME COMMON FOOT
DEFORMITIES
52. OSTEO-ARTICULAR ASSESMENT
Standard X-ray
Signs of Osteitis.
Neuro - arthropathic lesions
Comparative assessment
CT
confirms osteolysis in case of ambiguous X-ray
MRI
It differentiates osteoarthritic from neurogenic osteo-arthropathic lesions
Reserve it for ‘‘acute foot’’ with cellulitis
Sometimes USG for aspiration
53. MANAGEMENT
DIABETIC FOOT NEEDS MULTIDICPLINARY
APPORCH
DEVELOPED COUNTRIES
TEAM CONSISTS OF
1. PHYSICIAN
2. SURGEON
3. PODIATRIST
4. SPECIALIST NURSE
5. ORTHOTIST
6. RADIOLOGIST
DEVELOPING COUNTRIES
THE PRIMARY CARE DOCTOR IS THE ONLY
HELP AVAILABLE
ORTHOTIST, PODIATRIST, SPECIALIST NURSE
ALL EXTREMELY SCARCE
THEREFORE, BASIC ASPECTS OF ALL THESE
FIELDS NEED TO BE KNOWN BY EVERY
PHYSICIAN
54. ASPECTS OF PATIENT TREATMENT
CONTROL OF WOUND OR ULCER SPREAD
CONTROL OF DIABETES
CONTROL OF INFECTION
USE OF MECHANICAL INSTRUMENTS
AMPUTATION
REVASCULARIZATION
EDUCATIONAL CONTROL
55. CONTROL OF WOUND OR ULCER
SPREAD
WOUND CLEANSING & DRESSING
A sterile, non-adherent dressing should
cover all open diabetic foot lesions to
protect them from trauma, absorb exudate,
reduce infection and promote healing.
Dressings should be lifted every day to
ensure that problems or complications are
detected quickly, especially in patients who
lack nociception.
ADDITIONAL APPROCH
Skin graft:
Vacuum-Assisted closure (VAC) pump:
56. DEBRIDMENT OF ULCER
Forcep and a scalpel is the usual technique
by cutting away of all slough and non-viable
tissue.
Debridement is the removal of necrotic and dead
tissue in order to enhance healing.
Remove callus in neuropathic foot to lower plantar
pressure
Assess the true dimension of the ulcer
Drain exudate and remove dead tissue to render
infection less likely
Take a deep swab for culture
Encourage healing and restore a chronic wound to an
acute wound
58. CONTROL OF INFECTION
Choose an antibiotic regimen
Severe infection:
start broad spectrum IV abx (ensure Gram Positive Coverage, gram
negative and anaerobic coverage)
Mild-Moderate infection:
Relatively narrow spectrum only covering aerobic Gram Positive
Coverage
No evidence for anti-anaerobic therapy
Oral therapy with highly bioavailable agents is appropriate
Mildly infected open wounds with minimal cellulitis:
Limited data support the use of topical antimicrobial therapy (B-I)
59. USE OF MECHANICAL INSTRUMENT
Plantar orthoses –
• Insoles have a preventive and sometimes curative
function.
• Basically, they distribute pressure, more rarely with
corrective elements
Orthoplasties –
• Orthoplasties are little molded silicone devices that
protect areas of conflict with the shoe (notably at the
toes)
Shoes –
• Shoes are essential to prevention.
• They may be adapted mass-produced models, semi-
therapeutic or made to measure orthopedic shoes
60. Various casts are available and all aim to relieve
plantar pressure. Their use is governed by local
experience and expertise
Air cast (walking brace)
A bivalved cast with the halves joined together with Velcro strapping. The
cast is lined with 4 air cells which can be inflated with a hand pump to
ensure a close fit. The cast can be removed easily by patients to check
ulcers and before going to bed.
Scotch cast boot
A simple, removable boot madeup of stockinette, softban bandage, belt
fibreglass tape.
Total contact cast
It is a close-fitting plaster of paris and fibreglass cast applied over
padding. It is very efficient method of redistributing plantar pressure, and
should be reserved for plantar ulcers that have not responded to other
A scotch cast boot
An air cast
61.
62.
63. AMPUTATION
Indications for amputation are:
1. If revascularization is technically impossible
2. If there is substantial tissue necrosis and
functionally useless foot or spreading
infection is present
3. A non healing ulcer that is accompanied by a
higher burden of disease than would result
from amputation.
4. Ischemic rest pain that cannot be managed by
analgesics or revascularization
5. As part of debridement (minor amputation)
6. Spreading cellulitis
65. EDUCATIONAL CONTROL
DIABETIC FOOT CARE
DO
WASH FEET DAILY WITH MILD SOAP & WATER
CHECK FEET DAILY
TAKE URGENT TREATMENT OF ANY
PROBLEMS
WEAR SENSIBLE SHOES
CHECK SHOES INSIDE AND OUTSIDE BEFORE
WEARING
MEASURE FEET WHEN BUYING SHOES
BUY LACE-UP SHOES WITH PLENTY OF ROOM
FOR TOES
KEEP FEET AWAY FROM HEAT
SIT INSTEAD OF STANDING
CHANGE SOCKS FREQUENTLY
DONTS
USE CORN CURES
USE HOT-WATER BOTTLES
WALK BAREFOOT
CUT CORNS OR CALLUSES BY YOURSELF
DELAY IN TREATMENT FOR ANY PROBLEM
66.
67. PROGRAM CONDUCTED BY
GOVERNMENT OF INDIA
NPCDCS (National Program For Prevention And Control Of Cancer,
diabetes, cardiovascular diseases, and stroke )
The three main types of diabetes – type 1 diabetes, type 2 diabetes and gestational diabetes –occur when the body cannot produce enough of the hormone insulin or cannot use insulin effectively. Insulin acts as a key that lets the body’s cells take in glucose and use it as energy. People with type 1 diabetes, the result of an autoimmune process with very sudden onset, need insulin therapy to survive. Type 2 diabetes, on the other hand, can go unnoticed and undiagnosed for years. In such cases, those affected are unaware of the long-term damage being caused by their disease. Gestational diabetes, which appears during pregnancy, can lead to serious health risks to the mother and her infant and increase the risk for developing type 2 diabetes later in life.
382 million people have diabetes
90% Type II
The greatest number of people with diabetes are between 40 and 59 years of age
Asians shows more vulnerability
Global prevalence-8.3%
80% of people with diabetes live in low and middle income countries
Diabetes caused 5.1 million deaths in 2013
Every six seconds a person dies from diabetes
11% of total health spending in adults in 2013.