By : Dimas Aryo Kusumo 27-04-1011 pembimbing Dr Wahyu SpB KTV

Prevalence diabetic foot : > , world wide now exceeds 200 milion next 20 years become 300 milion

Complication diabetic foot PAD ( peripheral arterial disease ) with infection medical emergency

Most important underlying is neuropathy ( sensory , motor, and autonom ) Sensory protective sensation < Motor muscle atrophy , foot diabetic Autonom dry skin PAD

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Skin and Integument A. Color B. Temperature C. Texture D. Hair Growth E. Moisture F. Lesions-location, size, type G. Condition of toenails

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Vascular exam A. Color B. CFT C. Varicosities/Edema D. Pulses (DP and PT)

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Neurological A. Light touch B. Sharp-dull discrimination C. Vibratory D. Proprioception E. Protective sensation F. DTR

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Musculoskeletal A. General appearance(gross deformities) B. Muscle strength/function C. Muscle tone D. ROM

Diabetic foot with no infection Neurotraumatic

Decreased sensation + repetitive trauma = joint and bone collapse

Neurovascular
Increased blood flow increased osteoclast activity osteopenia Bony collapse Glycolization of ligaments brittle and fail Joint collapse

Can be lead severe soft tissue and osseous infection Symtoms : cellulitis , lymphangitis or purulent discharge with sepsis Pro surgical intervention Lab : complete blood count , glucose level , Hg A-1c , albumin , erythrocyte sedimentation rate ( ESR) , culture for appropriate antibiotic

Bone biopsi gold standard Plain radiographs, with contralateral uninvolve foot radiolucency ( 5-7 days) , 10-14 days ( sequester and involucrum ) , soft tissue edema , gas . After operation ,check again day 14 MRI most accurate CT scan Bone scintigraphy For best imaging is : MRI with bone biopsi

Non limb threatening - superficial ulcer and less than 2 cm of sorrounding cellulitis with absence leukocytosis

Lim threatening - Edematous , more than 2 cm sorrounding cellulitis , sepsis

WAGNER CLASSIFICATION FOR DIABETIC FOOT LESIONS Grade 0 No open lesion(callus may be present)

Grade 1 Superficial Ulcer

Grade 2 Deep Ulcer to Tendon, Capsule or Bone

WAGNER CLASSIFICATION FOR DIABETIC FOOT LESIONS Grade 3 Deep Ulcer with abscess, osteomyelitis, joint sepsis Grade 4 Localized gangrene

Grade 5 Gangrene of entire foot

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2.

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Location diabetic foot wound important for appropriate treatment ulcer on posterior border heel cb cronic pressure , friction cb bed sheet , and lack heel elevation heel suspension pillow cocoon Ulcer on plantar foot cb deformity foot ( prominent osseus segmen ) decrease weight bearing with wheelchair , total contact cast Ulcer on dorsal aspect of the toes

DESCRIPTION SIZE(L x W x D) DURATION LOCATION DRAINAGE/INFECTION ODOR BASE/RIM

1. 2. 3. 4. 5.

TREATMENT PROTOCOL GRADE 0 Proper shoe/orthotics Education Palliative Podiatric care Prophylactic surgery Prevention

Total contact cast Distributes pressure and allows patients to continue ambulation Principles of application
Changes, Padding, removal

Antibiotics if infected

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TREATMENT PROTOCOL GRADE 1 Antibiotic therapy Wound care Radiographs Surgery Same as Grade 0

Antibiotic prophylactic culture and sensitifity Non completely clear for dosage and duration

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TREATMENT PROTOCOL GRADE 3 Hospitalize/IV abx Aggressive I&D/Debridement Radiograph/Bone scan/MRI r/o OM Metabolic control Plastic surgical closure prn

Wagner 4-5

Amputation
? level

Uncontrollable infection or sepsis Inability to obtain a plantar grade, dry foot that can tolerate weight bearing Non-ambulatory patient Decision not always straightforward

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Vascular anatomy of the foot , 4 zones Proximal plantar area Midplantar area Lateral foot Distal foot 10 compartement can require decomprescion with surgical incision (1) Skin , (2) medial, ( 3 ) superficial central (4) deep central ( 5) lateral (6-9) interoseus (10) calcaneus compartement

Incision not be place down to bone for maintain cutaneus vascularity and promote primary bone closure Asuperficial sentral , deep central, calcaeal compartement B peroneal tendon and lateral compartement of leg C interosseus compartements D every compartement excepts dorsal plantar facia

If bone expose or suspect osteomyelitis bone culture and performed application polymethylmethacrylate antibiotic loaded cement ( PMMA-ALC ) Serial debridement is performed as needed as obtain stable wound free necrotic tissue For wound care use 1 liter saline to irigation with pressure or power hydro dissection tool to vacuum necrotic tissue

Important to identify PAD because increase risk amputation Infection / ulceration increase blood demand from foot

30 times more prevalent in diabetics Diabetics get arthrosclerosis obliterans or lead pipe arteries Calcification of the media Often increased blood flow with lack of elastic properties of the arterioles Not considered to be a primary cause of foot ulcers

Vascular

Assessment of peripheral pulses of paramount importance If any concern, vascular assessment

ABI (n>0.45) Sclerotic vessels Toe pressures (n>40-50mmHg) TcO2 >30 mmHg Expensive but helpful in amp. level

Percutaneus angioplasty with or without stent Laser or resectional artherectomy