Early Detection and

Prevention of Diabetic Foot

 Learning Objectives

• Identify risk factors and strategies for early

detection of diabetic foot

• Explain the pathophysiology and etiology of

diabetic foot
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

Every 30 seconds a lower limb lost caused by diabetes

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
 15 %
Outcome 50 %

35 %

No amputation
no amputation Amputation
amputation Death
death

(5) 12%
(3) 7%

Improved
(5) 12%
(19) 44% Minor Amputation
Major Amputation
(11) 25% Died
Self request
discharge

n = 43 patients Source:
Speaker Meeting
Em Yunir, Kyoto Foot Meeting 2012 Kyoto Foot Meeting 2008
Pathophysiology of Diabetic Foot
 Risk Factors of Diabetic Foot

Peripheral neuropathy
Peripheral vascular disease ( PAD )
Foot Deformities/ biomecanic
History of ulcer or amputation
Non suitable footwear
Lack of access to health care
services

Edmond M, 2006
 Risk Factors

10/1/2016 Kyoto Foot Meeting 2010 7

Peripheral Neuropathy

1. Autonomic Neuropathy
2. Motor Neuropathy
3. Sensoric Neuropathy
Autonomic neuropathy

Decreased sweating

Dry skin

Decreased elasticity

Repetitive Shears &
Pressures

Callus/ Fissure

Ulcer
 Sensoric neuropathy

• Loss protective sensation

• Decreased of pain threshold
• Lack of temperature sensation and proprioseption

Ill fitting shoes

Thermal trauma by hot water
Thermal trauma in `bajaj`
Somatic Motor Neuropathy
kaki :
Small muscle
wasting/hypotrophy

foot deformities
bone prominent

Increased foot pressure

Ulcer
 Peripheral Arterial Disease

• Correlated with atherosclerosis

•  A1c 1 % 26 % PAD
• More aggressive
• Narrowing vessel lumen … obstructive
• Distal tissue necrosis
 Macrocirculation
Plaque
Athero- Rupture/
Fatty Fibrous sclerotic Fissure & Myocardial
Normal Streak Plaque Plaque Thrombosis Infarction

Ischemic
Stroke

Critical
Leg
Clinically Silent
Ischemia
Angina, TIA`s, PAD
Cardiovascul
ar Death
Increasing Age
 Diabetic Foot Examination

Assesment Test Significants Findings

Patients History Interview Previous foot ulceration
Previous amputation
Diabetic > 10 years
A1c > 7 %
Impaired vision
Neuropatic symptoms
Claudicatio
Assesment Significant finding
Gross inspection Hammartoes
Claw toes
Halux valgus
Deformity

Hammer toes
Pes Cavus
Prominent MTP I Claw toes
Assesment Significant finding
Gross inspection Deformities, Corn, calluses, bunion
Callus with ulcer
Prominent metatarsal head
Callus (1)

Callus + ulkus
Callus
Assesment Significant finding
Dermatologic examination Dry skin
Absence of hair
Yellow or erythematous scale
Ulcer
Heal Ulcer
Assesment Significant finding
Dermatologic examination Interspace maseration
Moist
Uhealing ulceration
Assesment Significant finding
Nail deformities Yellow, thickened nail
Ingrowing nail edge
Long or sharp nail
Assesment Test Significant finding
Screening for Semmes-Weinstein Lack of perseption at
neuropathy monofilamen 10 gram one or more side
Assesment Test Significant finding
Screening for Tuning fork 128 Hz Negative of vibration
neuropathy perception
Assesment Test Significant finding
Vascular •Palpation of dorsalis • Decrease or absent
Examination pedis and tibialis pulse
posterior arteri
•Ankle Brachial Index • ABI < 0.9 consistent
( ABI ) with PAD
•Color doppler
Measurement of the Ankle–Brachial Index (ABI).

Source: American Heart Association

Interpreting the Ankle-Brachial pressure Index ( ABI )

ABI Interpreting
>1.2 Rigid or calcified vessels or both

0.9 – 1.1/1.2 Normal (or calcified)

<0.9 Ischaemia

<0.6 Severe ischaemia

Source: American Diabetes Association  Cek nilai
ABI tertinggi versi ADA 2015
 Clinical Manifestation
Grade 1 Grade 2 Grade 3 Grade 4 Grade 5 Grade 6

Normal High risk Ulcus Infection foot Necrosis/ Irreversible

Deformity Ulcus at plantar Edema gangren foot --, Extensive
Nail abnormality Neuropathy Rash cutis, subcutis necrosis, should
fascia, joint. be treated with
Dry skin Callus Infection
amputation
Hypotrophy Muscle at the Osteomyelitis
muscle bottom Systemic
symptoms

Wagner Classification
5 Cornerstones of Foot Management

Foot
examination

Treatment Classification
before ulcer risk factors

Appropriate
Education
footwear
Prevention Program
Do:
1. Check and take a look your feet everyday
2. Always using footwear
3. Check your shoes before wearing
4. Wearing proper shoes
5. Buy shoes in afternoon
6. Always wearing cotton socks
7. Wash your feet with smooth soap, dry it
8. Clipping nail horizontally
9. Check your feet to health care professional
regularly
10. Use moisturizing lotion regularly
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
Skin (1)
Skin (2)

Bulu kaki yang menipis Atrofi jaringan subkutan

 Skin (3)

Ulkus
Warna kulit kaki kemerahan Tinea ( jamur )
Bulla
hiperpigentasi
Skin (4)

Maserasi kulit pada Bullae (tangan)

sela jari
Nail (1)

1. Structure :
- atrophy
- hypertrophy
- fragile
Kuku(2)

2. Change of color
3. Abnormality of nail growth
4. Infection
Nail Abnormalities
Swelling
Deformities

Hammer toes
Pes Cavus
Halux valgus Claw toes
Case Studies
Clinical Features and Diagnosis?
Mention physical abnormalities on below
picture