Diabetic Foot PDF

Diabetic foot Introduction  Definition:  Common complication of diabetes mellitus, resulting in infection, ulceration, and possibly lower-extremity amputation.  Prevalence:  Up to 25% of patients with diabetes are at risk of developing a foot ulcer.  50% of diabetic foot ulcers become infe...

Diabetic foot Introduction  Definition:  Common complication of diabetes mellitus, resulting in infection, ulceration, and possibly lower-extremity amputation.  Prevalence:  Up to 25% of patients with diabetes are at risk of developing a foot ulcer.  50% of diabetic foot ulcers become infected, leading to a higher risk of hospitalization and amputation.  Significance of Early Detection:  Timely intervention can prevent ulcers from progressing and reduce the risk of severe complications. Pathophysiology  Diabetic Neuropathy (most common cause):  Sensory Neuropathy:  Loss of protective sensation, leading to unrecognized injuries from minor trauma.  Motor Neuropathy:  Causes muscle atrophy in the foot, leading to deformities (e.g., hammertoes, claw toes) and uneven weight distribution.  Autonomic Neuropathy:  Leads to reduced sweating and dry, cracked skin, making skin more prone to injury and infection.  Peripheral Arterial Disease (PAD):  Narrowing of blood vessels results in reduced blood flow to the lower extremities.  Impaired healing and increased susceptibility to infection.  Immune Dysfunction:  Chronic hyperglycemia impairs neutrophil function and cellular immunity.  Delayed response to infections and ineffective wound healing.  Risk factors  Patient-Related Factors:  Long-standing diabetes (>10 years), poor glycemic control (high HbA1c).  History of previous foot ulceration or amputation.  Comorbid conditions like hypertension, hyperlipidemia, and obesity.  Lifestyle Factors:  Smoking (increases PAD risk), lack of physical activity.  Use of inappropriate footwear leading to repeated trauma.  Foot Abnormalities:  Bony deformities and calluses, which increase pressure points and the risk of ulceration. Clinical presentation  Symptoms of Neuropathy:  Tingling, burning, or numbness in the feet, loss of sensation.  Signs of Peripheral Arterial Disease (PAD):  Diminished or absent foot pulses, coldness, pallor, or bluish discoloration of the skin.  Signs of Infection or Ulceration:  Persistent sores or wounds, swelling, redness, and warmth, foul odor or pus discharge.  Charcot Foot: (Neuropathic osteoarthropathy)  Progressive destruction of bones and joints, leading to foot deformities.  Presents with a warm, swollen, and often painless foot.   Wagner Classification (Most Commonly Used): Classification  Grade 0: No open lesion but a high-risk foot (callosities, deformities).  Grade 1: Superficial ulcer.  Grade 2: Deeper ulcer involving tendons, bones, or joints.  Grade 3: Ulcer with abscess formation or osteomyelitis.  Grade 4: Partial gangrene of the foot or toes.  Grade 5: Extensive gangrene requiring limb amputation. Diagnosis  History and Physical Examination:  Patient history: duration of diabetes, glycemic control, smoking status.  Physical exam: check for pulse (dorsalis pedis, posterior tibial), signs of neuropathy, skin breakdown, deformities.  Vascular Studies:  Ankle-Brachial Index (ABI): Assesses blood flow (ABI < 0.9 indicates PAD).  Toe Pressure or Transcutaneous Oxygen Tension (TcPO2): Helps in severe PAD assessment.  Neurological Testing:  Monofilament Test: Evaluates pressure sensation.  Vibration Perception Test: Uses a tuning fork to check vibration sense.  Imaging:  X-rays: Look for bone deformities or osteomyelitis.  MRI: Helpful to detect deep infections and soft tissue involvement. Management  Wound Care:  Debridement: Removal of necrotic tissue to promote healing.  Dressings: Use of moisture-retentive dressings or advanced dressings.  Infection Management:  Antibiotics: Empiric broad-spectrum antibiotics, tailored based on culture results.  Hospitalization for severe infections or systemic signs.  Offloading Techniques:  Total Contact Casting (TCC): Gold standard for reducing pressure.  Custom Footwear and Insoles: For long-term pressure distribution.  Surgical Intervention:  Minor Surgery: Drainage, debridement, tendon lengthening.  Major Surgery: Amputation if there is gangrene or severe infection.  Blood Glucose Control:  Intensive insulin therapy or antidiabetic medications to promote healing.  Regular HbA1c checks to maintain target levels (