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Diabetic foot

Definition:
A spectrum of foot disorders ranging from ulceration to gangrene in diabetic pt as a result of peripheral neuropathy or ischemia or both. WHO definition.. It is the foot of the diabetic pt that has the potential risk of pathological consequences, including infection, ulceration, and /or destruction of deep tissue associated with neurological abnormalities, various degrees of peripheral vascular disease, and/or metabolic complication of diabetic in lower limbs. Classification: i. Neuropathic foot. ii. Neuroischemic foot. iii. Diabetic foot infection. i. The Neuropathic foot..

Pathogenesis: Vascular hypothesis:

by occlusion of the vaso vasorum.

Metabolic hypothesis:

Hyperglycemia accumulation of sugar in schwan cells disruption of their function& structure and delayed nerve conduction lead to neuropathy.

Types of neuropathy:
1. autonomic neuropathy.. - loss of sweating. - Callous formation.

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sensory neuropathy.. extrinsic foot lesion. Symmetrical. Loss of vibration sense (1st to occur). Loss of temperature &pain sensation. Loss of proprioception &joint position sense.

3. motor neuropathy - intrinsic lesion subluxation. charcots joint.

Clinical manifestation of neuropathic foot:

warm. Numb. Dry. Painless. Palpable pulse. Presence of granulation tissue (good sign of healing).

Complication:
1. unrecognized trauma lead to ulceration, infection. 2. charcots joint. 3. neuropathic edema(rarely). Neuropathic ulcer.. - Site: the planter surfaces of the metatarsal heads and toes. - Could be infected with staph/ strept. If untreated. - Causes: 1.peripheral nerve lesions e.g. diabetes, nerve injury, leprosy. 2.spinal cord lesions e.g. spina bifida, tabs dorsalis, syringomyelia. - Ttt: remove callous, swap, oral AB and special foot wear. Charcots joint.. - precipitating usually by minor traumatic episode. - Presented as swollen, erythematous, hot, painful(sometimes) joint. - Most commonly involved: metatarsal- tarsal joint. - Management: immobilization.

Neuropathic edema.. - uncommon. - Sever peripheral neuropathy. - Swelling of feet and lower leg. ii. The Neuroischemic foot.. The purely ischemic foot with no concomitant neuropathy is rarely seen in diabetic pts and its management is the same as for Neuroischemic foot. Pathogenesis: Ischemia as a result of angiopathy. Diabetic angiopathy classified into two types: 1. microangiopathy affects the small blood vessels throughout the body but it is particularly dangerous in *retina blindness. *renal glomeruli end stage renal disease(ESRD). *nerve sheath neuropathy. 2. macroangiopathy affects large BV like *coronary artery ischemic heart disease. *cerebral artery stroke. *peripheral artery acute / chronic intermittent claudication/ trophic changes. Atherosclerosis of the vessels of the leg & neuropathy predisposing to minor trauma. The atherosclerosis is multi-segmental, bilateral, and distal. Involves: popliteal, tibial, peroneal arteries. Smoking, hypertension, and hyperlipidemia commonly contribute.

Clinical signs &symptoms:

pain. Absent pulses. Thinned or shiny skin. Absence of hair. claudication. ulceration. thickened nails. gangrene.

Vascular ulcer.. - The wounds heal poorly. - Minor trauma cause ulcer present as area of necrosis surrounded by a rim of erythema, often painful, cold, no callous, at edge of foot or toes. - Investigation: Transcutaneous oxygen measurement The ankle brachial index(ABI).. Not accurate (false +ve), because of calcification of arterial walls in diabetic foot (arteries are stiff, not squashed by the pressure cuff. normal ABI=1, if 0.8ischemia, if 0.5rest pain, if less than that gangrene/ ulcer. Absolute toe systolic pressure.. More accurate. - management: 1. if ulcer is small, shallow, recent medical ttt (insulin, anticoagulant, opiate). 2. remove necrotic tissue, ulcer swap, clean, dressed. 3. if infected: drainage, specific antibiotic therapy. 4. sever sepsis: emergency admission Iv AB, surgical debridement, angioplasty or bypass surgery. * if the ulcer is acute there will be granulation tissue & bleeding, if ulcer is chronic there will be slough in the floor, thickening of the edge, and pigmentation around the ulcer. * if any lesion however small, in the pulse less foot has not respond to conservative ttt within 4 weeks then the pt should be considered for arteriography & revascularization. * other causes of ischemic ulcer: Large artery obliteration: - atherosclerosis. - embolism. Small artery obliteration: - scleroderma. Buergers disease. - embolism. diabetes.

- physical agents e.g. pressure necrosis, radiation, trauma, electrical burns.

Gangrene.. - it is the end point of Neuroischemic foot due to macroangiopathy. - Mainly the big toe is involved. - Manifested as black discoloration and deeper tissue necrosis. - If only the artery is blocked dry gangrene(dark, dry, hard, shrunken with clear line of demarcation) wait for autoamputation then reconstruct. - If both artery and vein are blocked, the blood will remain in the vessels wet gangrene(soft, swollen, infected, malodorous without clear line of demarcation) amputation. *atherosclerosis cause slow &progressive blockage of the artery dry gangrene. * diabetic gangrene is often associated with gas in the tissue (tissue crepitus) and foul smell. - there will be loss of pulse, sensation, temp &function and changes in color. - The dead tissue will rotten & invite anaerobic infection (gas gangrene) crepitation on palpation& air bubbles on xrays. characteristics Skin temp. Pain. Skin color. Callous. Ulcer Peripheral pulse Neuropathic foot Warm Painless No change Thick at pressure points Planter ulceration at pressure points Bounding Neuroischemic foot Cold Painful Dependent rubor(red) May or may not present At tips of toes/over pressure areas Not palpable

Beside ulcer and gangrene diabetic foot can also present as diabetic foot infection, which ranges from simple superficial cellulites to chronic osteomyelitis. Cellulites.. - tender erythematous non-raised skin lesions on the lower extremity that may or may not be accompanied by lymphangitis. - No ulcer or wound exudates. - Caused by group A streptococcus. Deep skin& soft tissue infection.. - Acutely ill, with painful indurations of the soft tissues in the extremity. - Common in thigh area, but they may be seen any where on leg or foot. - Wound discharge usually not present. - In mixed infection that may involve anaerobes, crepitation may be noted over the afflicted area. - Extreme pain &tenderness compartment syndrome, closteridial species i.e. gas gangrene. Osteomyelitis.. - Results from contiguous spread of deep tissue infection through cortex to bone marrow. - Associated with deep long standing foot infection. - no lymphangitis. - pain may or may not present. - usually are located between toes or on the planter surface of the foot. - diagnostic feature: chronic discharging sinus or sausage like appearance of toe. - early osteomyelitis doesnt show up on x-ray so, we use CT/ MRI and bone biopsy to confirm. - ttt of choice: resection.

Differential diagnosis of diabetic foot: 1. wet gangrene. 2. arterial (atherosclerosis, burgers disease, aretritis) 3. venous (DVT, varicose veins(venous ulcer). 4. neuropathy (leprosy, tabes dorsalis, DM). 5. lymphatic obstruction. 6. malignancy (squamouse cell carcinoma). 7. systemic disease (Sickle cell disease, rheumatoid arthritis). 8. mycetoma, leshmania. History taking of diabetic foot: Diabetic history. Ulcer history: 1. Duration.. when was it 1st diagnosed? 2. 1st symptom.. what brought it to pt notice? 3. other symptoms.. what symptoms does it cause? 4. progression.. how has it changed since it was it 1st noticed? 5. persistence.. has it ever disappeared or healed? 6. multiplicity.. has the pt had any other ulcers? 7. causes.. what does the pt think cause it? Ask about symptoms of the differential diagnosis. Ask about risk factors e.g. hyperlipidemia, smoking. Examination : General.. systemic. Local .. before you start .. 1. expose both limbs. 2. compare both limbs.

3. examine lower limbs as a whole then examine the ulcer. I. inspection: a. signs of chronic ischemia(pallor, cold, atrophy): - atrophy of muscles. - hair loss. - atrophic nail. - shiny skin. b. Color.. white, pale, blue, black. c. Swelling. d. Pressure points.. base of 5th metatarsal, lateral side of the foot, head of 1st metatarsal, heel, malleoli.*look between toes and tips of toes. e. Ulcer.. - site, size, shape. - Edge, depth, floor. - Discharge, granulation/ necrotic tissues, surrounding tissues. II. palpation: Tenderness. Temperature. Base of the ulcer. Pulsation of: 1. dorsalis pedis. 2. posterior tibial. 3. popliteal. 4. femoral. sensation : touch, vibration and position sense is the 1 st to be lost in DM. Inguinal LN. If the foot is swollen; may be an abscess so, look for fluctuation, discharge sinuses and widening of space between the toes due to bus collection. If there is a sinus near the ulcer; look for deep infection; infection of bone or tendons.

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Investigations: 1. CBC.. leukocytosis. 2. Random& fasting blood sugar(RBS/FBS). 3. X-ray of the foot; to rule out: Osteomyelitis. Gas gangrene. Atherosclerosis. 4. Swab for culture& sensitivity. 5. check blood vessels by: Doppler U/S. Angiography. Arteriogram. * look for site &length of the block and presence of collateral.

Management.. a. prevention foot care: feet kept clean. Inter-digital space dry. Remove calluses. Toenails trimmed. Frequent inspection. Properly fitting shoes. Check water temperature before bathing.

b. specific management 1. Control diabetes..

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Any diabetic pt will be on insulin when he/she develops infection. 2. Antibiotic.. Ampicilin Gram +ve. Gentamycin Gram ve. Metronidazole/ flagyl Anaerobes. 3. Local debridment.. Remove necrotic tissue in the foot, because it is infected& good medium for infection. *if there is abscess incision & drainage. 4. Dressing.. Every day or every other day, use dry dressing. 5. In vascular abnormality.. - small abnormality dilate by balloon. - large abnormality bypass surgery. * in angiopathy we need both medical &surgical ttt. * in neuropathy we need to educate the patient &control the infection. Indication of amputation: Uncontrolled infection. Osteomyelitis. Extensive tissue destruction.

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How to describe an ischemic ulcer? -Site: tips of toes & over pressure areas. -Size: any size. -Shape: elliptical(oval), irregular. -Edge: punched out , but if healing begin sloping edge. The skin at the edge is usually blue-grey color. -Base: Contains grey yellow slough covering flat, pale-pink granulation tissue. -Depth: often deep. -Discharge: either clear fluid, serum or pus. -Temperature: surrounding tissue usually COLD because they are ischemic (warm, healthy tissue suggest another cause for ulceration). -Tenderness: the ulcer& surrounding tissue are very tender. -Relation: the base may be stuck to underlying tissue. Bare bone, ligaments, and tendon may be exposed. -Lymph drainage: the infection usually localized to the ulcer, so LN are not involved. -Local tissues: pallor, cold, atrophy, absent pulses.

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