Makindo Medical Notes.com

Related Subjects: Type 1 DM | Type 2 DM | Diabetes in Pregnancy | HbA1c | Diabetic Ketoacidosis (DKA) Adults | Hyperglycaemic Hyperosmolar State (HHS) | Diabetic Nephropathy | Diabetic Retinopathy | Diabetic Neuropathy | Diabetic Amyotrophy | Maturity Onset Diabetes of the Young (MODY) | Diabetes: Complications

Amputations are common but preventable and good care saves legs. Look for vasculopathy and neuropathy as well as bony deformity and skin and infection

About

• The mantra once taught that surgery was of no use that it was microvascular disease is unfounded
• Team approach with the surgeon, endocrine, radiology and microbiology

Aetiology is Multifactorial

• Vascular injury - atherosclerosis with vessel narrowing
• Tissue hyperglycaemia - infection
• Autonomic neuropathy - dry foot with no sweat, poor skin integrity
• Sensory neuropathy - more prone to injury
• Motor neuropathy - foot deformity

Clinical

• Ischaemia and ulcers and even necrotic tissue
• Reduced pulses, cold limb
• Motor/Sensory neuropathy - claw foot

Investigations

• FBC, U&E and Baseline clotting, Hba1C, CK (Rhabdomyolysis)
• ECG - AF, New MI. CXR - Cardiomegaly
• Dopplers of leg vessels looking for pulsation
• MR angiography to define vascular anatomy
• MRI may also show evidence of bone infection and osteomyelitis

Wagner Classification Diabetic foot ulcers

• Grade 0 : intact Skin
• Grade 1 : superficial ulcer of skin or subcutaneous tissue
• Grade 2 : ulcers extend into tendon, bone, or capsule
• Grade 3 : deep ulcer with osteomyelitis, or abscess
• Grade 4 : partial foot gangrene
• Grade 5 : whole foot gangrene

Predicts 6-month risk of amputation and mortality in diabetic foot ulcers. Use in an inpatient setting in patients with diabetic foot ulcer of any duration. Do not use in patients with secondary diabetes or those with foot ulcers caused by autoimmune disease or malignancy.

Management

• Ensure that people with T2DM have a foot check in primary care at diagnosis and at least once a year thereafter, or sooner if any foot problems arise.
• Give information on the risk of developing a diabetic foot problem at diagnosis, during reviews, and if foot problems arise, including
  • Basic foot care advice and the importance of foot care, including the need to check daily the entire surface of both feet, including areas between the toes. The Diabetes UK patient resource Diabetes and foot problems may be helpful.
  • Foot emergencies and who to contact
  • Avoid shoes that are too tight, have rough edges, or uneven seams; to avoid tight-fitting socks and change socks daily.
  • Nail-cutting advice
  • Recognition of ulcers
• Ask about risk factors
  • Previous foot ulcer or lower limb amputation, peripheral arterial disease, and end-stage renal disease (ESRD).
  • Symptoms of peripheral neuropathy
  • Symptoms of peripheral arterial disease (claudication or rest pain).
  • Foot care, including personal care and nail cutting.
  • Smoking history.
• Examine both feet fully for risk factors and signs of foot complications:
  • Peripheral neuropathy — a 10 g monofilament should be used as part of a foot sensory examination, to assess for loss of protective sensation (LOPS).
  • Diabetic foot disease may be asymptomatic in people with neuropathy due to loss of sensation.
• Peripheral arterial disease
  • Palpate pedal pulses and check ankle brachial pressure index (ABPI), if indicated.
  • Interpret ABPI results with caution, as calcification of pedal arteries may falsely elevate results.
• Ulceration
  • May be neuropathic (most commonly affecting plantar surface or areas overlying a bony deformity); neuroischaemic or ischaemic (most commonly affecting the tips of toes or lateral border of the foot).
  • Pre-ulcerative signs — callus, fissures, oedema, or blister formation.
  • Infection and/or inflammation (redness, warmth, induration, and pain/tenderness) or purulent discharge. See the CKS topics on
  • Paronychia - acute and Cellulitis - acute for more information. Note: typical findings may be reduced due to the presence of neuropathy and/or ischaemia.
  • Foot deformity (such as claw or hammer toes), large bony prominences, limited joint mobility.
  • Cellulitis: Look for signs of inflammation. Admit for IV antibiotics. Due to staphs, streps, anaerobes. Cover with Benzylpenicillin 1.2g/6h IV and flucloxacillin 1g/6h IV ± metronidazole 500mg/8h IV. IV insulin and better control may help healing. TVN/Vascular/Surgical review.
  • Surgical consult if Abscess or deep infection, spreading anaerobic infection, gangrene/rest pain, suppurative arthritis.
  • Charcot arthropathy: surgical review
    • An acute, localized inflammatory condition that may lead to varying degrees and patterns of bone destruction, subluxation, dislocation, and deformity.
    • If there is evidence of foot deformity and/or abnormal loading of the foot (for example callus formation), consider referral to podiatry for footwear advice and possible orthoses, specialist footwear, or splints.
    • Foot hygiene — improperly cut toenails, thickened or ingrown nails, unwashed feet, superficial fungal infection, unclean socks.
• Following foot examination, assess the person's foot ulceration risk category:
  • Low risk — no risk factors present.
  • Moderate risk — one risk factor present.
  • High risk — previous ulceration or amputation, on renal replacement therapy, or more than one risk factor present.
  • Active foot problem — ulceration; spreading infection; critical limb ischaemia; gangrene; suspected acute Charcot arthropathy (or an unexplained hot, red, swollen foot with or without pain).
• Arrange management depending on the person's foot ulceration risk category:
  • Those with a potentially limb- or life-threatening complication — arrange immediate referral to acute services.
  • For people with a non-limb- or life-threatening active foot problem — arrange urgent referral to the foot protection service (within 1 working day).
  • For people at high risk — arrange referral to the foot protection service to be seen within 2–4 weeks.
  • For people at moderate risk — arrange referral to the foot protection service to be seen within 6–8 weeks.
  • For people at low risk: Continue annual foot checks. Reinforce the importance of good foot care. Explain the risk of progression to moderate- or high-risk categories without appropriate foot care.
• Advise on the need for regular foot checks, depending on the risk of developing a foot problem:
  • Annually — for people who are at low risk.
  • Frequently (for example every 3–6 months) — for people who are at moderate risk.
  • More frequently (for example every 1–2 months) — for people who are at high risk, if there is no immediate concern.
  • Very frequently (for example every 1–2 weeks) — for people who are at high risk, if there is immediate concern. Note: more frequent reassessments should be considered for people who are unable to check their own feet.