Early Detection

and Prevention of
Diabetic Foot

Hemi Sinorita
 People with Diabetes

• Increased risk of hospitalized and infection

• Have a 15 % life time risk of developing foot ulcer
• Have 15 – 40 fold higher risk of leg amputation
• 85 % of amputations are preceded by foot ulcer
• Early detection can prevent 40-85 % lower limb
amputation

Frykberg RG, et al. J Foot Ankle Surg, 2000

IDF , International Working Group on Diabetic Foot 2007
 –10
Diabetes
0
duration (years) 20
10
IGT Type 2DM
Microvascular complications

Retinopathy, neuropathy, nephropathy

Macrovascular complications

DPP Research CHD

Group. N Engl J
Med 2002;
346:393–403.
2. Buchanan TA, et
Amputation
al. Diabetes
2002; 51:2796– Atherosclerosis Advance Blindness
8203. atherosclerosis On-going
3. Dormandy JA, et STROKE metabolic
al. Lancet 2005; Renal
366:1279–1289. CHD derangement
failure
PAD
 Pathophysiology of diabetic foot
Diabetes Mellitus

Neuropathy Trauma Vascular Disease

MOTORIC SENSORY AUTONOMIC MICROVASCULAR MACROVASCULAR
Weakness
Atrophy Anhidrosis dry Structural Structural
skin capillary BM atherosclerosis
Deformity Loss of thickening
Abnormal Protective Occlusive
Stress Sensation narrowing
Functional AV
High Plantar
Shunting
Pressure Sympathetic
Ischemia
Callus Tone
Formation

Structural
Impaired Response to
Deformity Infection Ischemia
Cheiroarthropathy
Amputation Diabetic Foot Ulcer Amputation

Diabetic Foot Disorders: A Clinical Practice Guideline (2006 Revision)

 Intrinsic Factors
Peripheral Neuropathy

Motoric
Weakness Atrophy

Deformity

Abnormal Stress

High Plantar Pressure

Callus Formation
Intrinsic Factors
Peripheral Neuropathy

Autonomic
Decreased Sweating

Dry Skin

Decreased Elasticity

Fissure

Ulcer
 Intrinsic Factors
Peripheral Neuropathy

Sensoric
• Loss of protective
sensation
• Decreased pain
threshold
• Lack of temperature
sensation and
proprioception
Intrinsic Factors

What is Peripheral Arterial Disease?

Non coronary arterial syndromes.

The altered structure and function
of the arteries that supply the
brain, visceral organs, and the
limbs.
 Intrinsic Factors
Peripheral Arterial Disease (PAD)

PAD
• A1c 1%  26 % PAD
Risk Factors* • Narrowing vessel lumen - obstructive
• Distal tissue necrosis
1. Smoking.
2. Diabetes.
3. Obesity (a BMI >30)
4. High blood pressure.
5. High cholesterol.
6. Age, >50 years of age
7. A family history.

* UKPDS
 Risk Factors for diabetic foot ulceration

Extrinsic Factors

1. Minor mechanical trauma

2. Thermal Injury
3. Chemical Burns
4. Improper use of nail cutter
1
2 5. Smoking
6. Poor knowledge of diabetes
7. Psychological Factors
8. Alternative medication

Frykberg, Diabetic Microvascular Complications Today, May/June 2006

 Pathophysiology of Diabetic Foot
Peripheral Neuropathy Peripheral Arterial Disease
Autonomic Motoric
Sensoric
 Neuroischaemic Ulcer

Charcot foot.
Pathway to diabetic foot ulceration

100% 2
2
90%
80% 78% 77%
70% 63%
60% 1
50%
40% 37% 35%
30%
30%
20%
10%
1%
0%
Peripheral Minor Deformity Edema Peripheral Callus Infections
Neuropathy Trauma Ischemia
Components leading to foot ulceration

Slide 13
Reiber GE, Vileikyte, Boyko EJ et al. Causal pathways for incident lower–extremity ulcers in patients with from two settings. Diabetes Care 1999: 157-
162
6 Steps for a complete Diabetes Foot Examination
Assessment Significant Finding

1.Patient - Previous foot ulceration

History - Previous amputation
- Diabetic > 10 years
- A1c > 7 %
- Impaired vision
- Neuropathic symptoms
- Claudicatio
 Major Symptoms of PAD
(Fontaine’s classification)

IIa III Pain at rest

Feeling of coldness,
Numbness

IIb Intermittent claudication

IV Ulceration, Necrosis
6 Steps for a complete Diabetes Foot Examination
Assessment Significant Finding
2.Gross - Hammer toes/ - Claw toes
Inspection - Halux valgus/bunion
- Corn, callus/ with ulcer
- Prominent metatarsal head
6 Steps for a complete Diabetes Foot Examination

Assessment Significant Finding

3.Dermatologic - Dry skin
Examination - Absence of hair
- Yellow or erythematous scale
- Ulcer or healed ulcer
- Interspace maceration
- Moist
- Unhealing ulceration
6 Steps for a complete Diabetes Foot Examination

Assessment Significant Finding

4.Nail - Yellow, thickened nail
Deformities - Ingrowing nail edge
- Long or sharp nails
Assesment Test Significant finding

5. Screening Semmes-Weinstein Lack of perseption at

for neuropathy monofilamen 10 gram one or more side
6. The First Tool to Establish the PAD Diagnosis:
A Standardized Physical Examination

Pulse intensity should be assessed and should be recorded numerically as

follows:
Dorsal pedis Posterior tibial artery
0, absent
1, diminished
2, normal
3, bounding

Popliteal artery
 Measurement of the Ankle–Brachial Index (ABI).

Source: American Heart Association

 Clinical Classification of diabetic foot (Edmond)

Grade 1 Grade 2 Grade 3 Grade 4 Grade 5 Grade 6

Normal foot, No active Skin Foot develop Tissue Unsalvageable

no risk ulcers, have breakdown; infections, necrosis foot, need
factors of ≥1 risk fisurre, Discharge with or with major
neuropathy, factors: blitser, ulcer purulent, out intake amputation,
ischemia, neuropathy, Usually in cellulitis, foot, extensive
deformities ischemia, plantar neuropathy neuropathy, necrosis,
deformities, surface and or ischemia, destroyed foot,
callus and ischemia neuroische severe
Slide
22
swelling, nail mi, infection infection
deformities
5 Cornerstones of Foot Management

Foot
examination

Treatment Classification
before ulcer risk factors

Appropriate Education
footwear
 Risk Classification based on Foot Assessment

Score Category Risk Profile Check-up Frequency

• Pulsation ADP and Once a year

0 Low Risk ATP good
• No deformities Encourage
(hammer toe, extended
claw toes, halux knowledge on
valgus, prominent diabetes and foot
metatarsal head) care
Encourage self-
care
 Education
Prevention of Diabetes Foot
DO
Check your feet everyday
Always wear footwear
Check your footwear before
wearing them
Use shoes that fit
Buy shoes in the afternoon
Always use socks of cotton
Wash your feet with soft
soap and dry them
Cut your nails in a flat way
Check your feet regularly at
the doctor
Use lotion regularly at your
skin
Education
Prevention of Diabetes Foot
DON’T’s
Walk without shoes
Use shoes that don’t fit
Use socks that don’t fit to your
foot
Let your skin become dry
Use sharp items to remove
warts
Smoke
Use ring on finger
Use high heels or shoes with
sharp edges
Over use of irritative lotion
Use hot water to dip your feet
Slide
27
 Risk Classification based on Foot Assessment

Score Category Risk Profile Check-up Frequency

Increased • Pulsation ADP Once every 6

1
Risk and ATP good months.
• And/or Inspect
deformities patient’s feet
(hammer toe, Review need for
claw toes, halux vascular
valgus, assessment
prominent Evaluate
metatarsal head) footwear
Enhance foot
care education
 Risk Classification based on Foot Assessment

Scor Catego Risk Profile Check-up Frequency

e ry
2 High • ABI < 0,9 or
Risk ADP/ ATP not
Once every 3 months
palpable
Inspect patient's feet
• Deformities
Review need for
(hammer toe,
vascular assessment
claw toes, halux
Intensified foot care
valgus, bunion)
education
Specialist footwear and
insoles
Skin and nail
 Risk Classification based on Foot Assessment

Score Category Risk Profile Check-up Frequency

• History of • Once every 1-3 months

3 Very ulcer or • Multidisciplinary foot
High amputation care team :
Risk • Ulcer • They should have
unhindered access to
suites for managing major
wounds,
• Urgent inpatient facilities
• Antibiotic administration
 Management of Diabetic Foot Ulcers
2

Metabolic
Control

1 3

Wound Infection
Control Control

5 4

Mechanic Vascular
Control Control
Slide
31
International Working Group on the Diabetic Foot 2007
Summary
 Diabetic foot is one of chronic complications of
diabetes
 Pathophysiology of diabetic foot ias very complex
 Slow healing process, risk for ulcus to be chronic and
high incidence of amputation
 Holistic management is mandatory and involving
multidisciplines
 Majority of ulcus or injury in diabetic foot can be
prevented with early detection and prevention at high
risk of foot