In: Kominsky SJ, ed. Medical and surgical management of the diabetic foot. Louis: Mosby, — Brand PW. The insensitive foot including leprosy. In: Jahss MH, ed. Philadelphia: Saunders, —5. The natural history of acute Charcot's arthropathy in a diabetic foot specialty clinic. Diabet Med. Increased uptake of bone radiopharmaceutical in diabetic neuropathy.
Q J Med. The neuropathic joint: a neurovascular bone disorder. Radiol Clin North Am. Plantar sensory threshold in the ulcerative foot. Lepr Rev. Choosing a practical screening instrument to identify patients at risk for diabetic foot ulceration. Arch Intern Med In press.
Relationship of limited joint mobility to abnormal foot pressures and diabetic foot ulceration. Limited joint mobility in childhood diabetes mellitus indicates increased risk for microvascular disease. Lower-extremity amputation in people with diabetes. Epidemiology and prevention.
Puncture wounds: normal laboratory values in the face of severe infection in diabetics and non-diabetics. Probing to bone in infected pedal ulcers. A clinical sign of underlying osteomyelitis in diabetic patients. Three-phase bone scan in osteomyelitis and other musculoskeletal disorders. Am Fam Physician. Classification of diabetic foot wounds.
J Foot Ankle Surg. Treatment-based classification system for assessment and care of diabetic feet. Identifying high risk patients for diabetic foot ulceration: practical criteria for screening. This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP.
Contact afpserv aafp. Want to use this article elsewhere? Get Permissions. Read the Issue. Sign Up Now. The Lower Extremity. Next: Seasonal Affective Disorders. Mar 15, Issue. TABLE 1 Risk Factors for Lower Extremity Amputation in the Diabetic Foot Absence of protective sensation due to peripheral neuropathy Arterial insufficiency Foot deformity and callus formation resulting in focal areas of high pressure Autonomic neuropathy causing decreased sweating and dry, fissured skin Limited joint mobility Obesity Impaired vision Poor glucose control leading to impaired wound healing Poor footwear that causes skin breakdown or inadequately protects the skin from high pressure and shear forces History of foot ulcer or lower extremity amputation.
Figure 3. Neuropathic ulceration of the foot in a diabetic patient. Figure 4. Read the full article. Get immediate access, anytime, anywhere. Choose a single article, issue, or full-access subscription. Earn up to 6 CME credits per issue. Purchase Access: See My Options close. Best Value! To see the full article, log in or purchase access. Not all ulcers are infected; however, if your podiatric physician diagnoses an infection, a treatment program of antibiotics, wound care, and possibly hospitalization will be necessary.
These devices will reduce the pressure and irritation to the ulcer area and help to speed the healing process. The science of wound care has advanced significantly over the past ten years.
We know that wounds and ulcers heal faster, with a lower risk of infection, if they are kept covered and moist. The use of full-strength betadine, peroxide, whirlpools and soaking are not recommended, as this could lead to further complications. Appropriate wound management includes the use of dressings and topically-applied medications. These range from normal saline to advanced products, such as growth factors, ulcer dressings, and skin substitutes that have been shown to be highly effective in healing foot ulcers.
For a wound to heal there must be adequate circulation to the ulcerated area. Your podiatrist may order evaluation test such as noninvasive studies and or consult a vascular surgeon. Tightly controlling blood glucose is of the utmost importance during the treatment of a diabetic foot ulcer. Working closely with a medical doctor or endocrinologist to accomplish this will enhance healing and reduce the risk of complications. A majority of noninfected foot ulcers are treated without surgery; however, when this fails, surgical management may be appropriate.
In diabetics more distal vessels below the trifurcation such as the peroneal, anterior, and posterior tibials are commonly involved. Surprisingly foot vessels such as the dorsalis pedis are often spared. Infection in a diabetic foot is a limb threatening condition because the consequences of deep infection in a diabetic foot are more disastrous than elsewhere mainly because of certain anatomical peculiarities. The foot has several compartments, which are inter-communicating and the infection can spread from one into another, and lack of pain allows the patient to continue ambulation further facilitating the spread.
The foot also has soft tissues, which cannot resist infection, like plantar aponeurosis, tendons, muscle sheaths, and fascia. A combination of neuropathy, ischemia, and hyperglycemia worsens the situation by reducing the defense mechanism.
Osteomyelitis generally results from a contiguous spread of deep soft tissue infection through the cortex to the bone marrow. A majority of deep, longstanding foot infections are associated with osteomyelitis. Diagnosing osteomyelitis in a patient with diabetic foot is often difficult. Major problems include differentiating soft tissue infection from bone infection and infections from non-infectious disorders Charcot Foot.
Plain radiography usually shows focal osteopenia, cortical erosions or periosteal reaction in the early stage and sequestration in the late stage. A simple clinical test is probing to the bone. A sterile metal probe is inserted into the ulcer if it penetrates to the bone it almost confirms the diagnosis of osteomyelitis.
Chronic discharging sinus and sausage-like appearance of the toe are the clinical markers of osteomyelitis. Definitive diagnosis requires obtaining a bone biopsy for microbial culture and histopathology.
The newer imaging techniques are nuclear bone scan, computerized tomography scan CT , positron emission tomography PET , and magnetic resonance imaging MRI. Of these, MRI is more sensitive and specific.
The Neuroischemic Foot, where occlusive vascular disease is the main factor, although neuropathy is present. Neuropathy leads to fissures, bullae, neuropathic Charcot joint, neuropathic edema, and digital necrosis.
Ischemia leads to pain at rest, ulceration on foot margins, digital necrosis, and gangrene. Differentiating between these entities is essential because their complications are different and they require different therapeutic strategies. Wound classification system[ 11 ]. The older classification, suggested by Wagner,[ 12 ] accounts only for wound depth and appearance and does not consider the presence of ischemia or infection.
Examination of the feet is an integral part of the physical examination of every patient, more so a diabetic patient. One should look for neuropathic changes like dry skin, fissures, deformities, callus, abnormal shape of foot, ulceration, prominent veins, and nail lesions. Careful attention should be given to the interdigital spaces. Significant ischemia is characterized by loss of hair on the dorsum of the foot and a dependent rubor. One should feel the foot for warmth or coldness; examine the peripheral pulsations such as dorsalis pedis, which can be felt lateral to the exensor hallucis longus tendon and posterior tibial, which is above and behind the medial malleolus.
The femoral artery should also be palpated and auscultated for the presence of bruit. The plantar aspects of the feet should be felt for the presence of any bony prominence or callus.
Sensory neuropathy can be tested by using monofilaments and biothesiometry. If these are not available, the detection of light touch by cotton wool, pinprick, and vibration sense using a Hz tuning fork is sufficient. The goal is to detect whether the patient has lost protective sensations LOPS , rendering him susceptible to foot ulceration.
A hand-held Doppler can be used to confirm the presence of pulses and to quantify the vascular supply. When used together with a sphygmomanometer, the ankle and brachial systolic pressures can be measured and the ratio then calculated. In normal subjects, the ankle systolic pressure is higher than the brachial systolic pressure. Diabetic foot should be managed using a multidisciplinary team approach. The management of diabetic foot ulcers includes several facets of care.
Offloading and debridement are considered vital to the healing process, for diabetic foot wounds. There are multiple methods of pressure relief, including total contact casting, half shoes, removable cast walkers, wheelchairs, and crutches. An open diabetic foot ulcer may require debridement if necrotic or unhealthy tissue is present.
The debridement of the wound will include the removal of the surrounding callus, which decreases the pressure points at the callused sites on the foot. Additionally, the removal of unhealthy tissue can aid in removing colonizing bacteria in the wound. It will also facilitate the collection of appropriate specimens for culture and permit examination for the involvement of deep tissues in the ulceration.
Infection in a diabetic foot is limb threatening and at times life threatening, and therefore, must be treated aggressively. Superficial infections should be treated with debridement, oral antibiotics, and regular dressings. Deep infections are considered when the signs of infection are combined with evidence of involvement of deeper tissue structures such as bones, tendons or muscles.
Creating a moist wound environment. Wound Care Wounds and ulcers heal faster and have a lower risk of infection if they are kept covered and moist, using dressings and topically-applied medications. Products including saline, growth factors, ulcer dressings, and skin substitutes are highly effective in healing foot ulcers. There should be adequate circulation to the ulcerated area.
Tight control of blood glucose is critical during to the effect treatment of a diabetic foot ulcer. This will enhance healing and reduce the risk of complications.
Surgical Options Many non-infected foot ulcers are treatable without surgery. However, surgery may be required to: Remove pressure on the affected area, including shaving or excision of bone s.
Healing time may range from weeks to several months, depending on: Wound size and location Pressure on the wound from walking or standing Degree of swelling Issues with proper circulation Blood glucose levels What treatments are being applied to the wound Risk Reduction The risk of developing a foot ulcer can be reduced by: Smoking cessation Lowering consumption of alcohol Reducing high cholesterol Controlling blood glucose levels Wearing the appropriate shoes and socks Inspecting feet every day—especially the sole and between the toes—for cuts, bruises, cracks, blisters, redness, ulcers, and other signs of abnormality.
Clinical Team Michael S. Gasper, M. Vascular Surgeon Jade S. Hiramoto, M. Vascular Surgeon James C. Iannuzzi, M. Reilly, M. Vascular Surgeon Peter A. Schneider, M.
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