Diabetic Foot

Ulcer
Presenter: Dr Candy Ting
Mentor: Dr Ridzuan

DIABETIC FOOT ULCER

Definition:
A breakdown in the skin of the foot that may extend to involve
the
subcutaneous tissue or even to the level of muscle or bone
that is associated with neuropathy and/or
peripheral arterial disease of the lower limb
in a patient with diabetes.

DIABETIC FOOT ULCER

Epidemiology:

Foot ulcerations and infections are the most common

reason
for a diabetic to be admitted to the hospital.

25 % of Diabetics

will develop a foot ulcer.

40-80% of these ulcers will become infected

10-30 % of patients with a diabetic foot ulcer will go on to

AMPUTATION

Global prevalence of diabetes: estimates for the year 2000 and projections for 2030.Diabetes Care 27:1047-1053, 2004

Natural history of diabetic foot

Its unwise to consider that major diabetic foot problem

occur all of sudden
There is high risk foot which means there are:

1- Predisposing factors (Neuro- and angiopathy)

2- Precipitating factors (Trauma and tinea infection)
3- Perpetuating factors (Pts factors & delay healing)

DFU itself result from the simultaneous

multiple contributing causes.

2 Major Factors
Peripheral Neuropathy
(More than 60% of DFU are
the result of underlying neuropathy)

Ischemia from
Peripheral Vascular Disease.

action of

DIABETIC FOOT ULCER

Pathophysiology of Foot Ulceration

Neuropathy in diabetic patients is manifested in the:
1. Motor
2. Autonomic
3. Sensory components of the nervous system

Motor Neuropathy

Damage to the innervations of the intrinsic foot muscles

leads to an imbalance between flexion and extension
of the affected foot.
This produces foot deformities that create
abnormal bony prominences and pressure points.

Architectural deformities

Hammer
toe

Claw toe

Abnormal bony
prominence

Increased pressure is placed on the

dorsal and plantar aspects of the
deformity

Formation of callus at pressure point

AREAS AT RISK OF ULCERATION

In which it will gradually cause skin breakdown and ulceration.

Marked callus formation at the

peak of the

Autonomic Neuropathy
Autonomic neuropathy leads to a
in sweat and oil gland dysfunction.
As a result,
the foot loses its natural ability to
moisturize the overlying skin and becomes dry
which predisposes to cracked skin & fissure formation &
subsequent development of infection.

Callus formation at pressure points and dry skin

are
substrate for ulceration

Marked callus build-up that is further accelerated by the dry skin.

The patient high risk for ulceration at these sites.

Sensory Neuropathy

Sensory perception is reduced resulting in loss of protective

reflexes against physical injury.
As trauma occurs at the affected site, patients are often unable to detect
the insult to their lower extremities.
As a result, many wounds go unnoticed and progressively worsen
as the affected area is continuously subjected to repetitive pressure and
shear forces from ambulation and weight bearing.

Unaware of a foreign body

Pressure in shoes (ill fitting shoes)
Abrasions in shoes
Tears or brakes in the skin

Sensory Neuropathy
Loss of pain sensation

STAGES OF ULCER DEVELOPMENT

Unnoticed trauma (thermal, chemical, mechanical)

Progression of lesion unchecked

Callous formation

Tissue necrosis & damage beneath callus

Development of cavities filled with serous fluid

Erupt into surface

Results in ulcer formation

STAGES OF ULCER DEVELOPMENT

Tissue necrosis & damage beneath

callus Development of cavities filled
with serous fluid

STAGES OF ULCER DEVELOPMENT

Erupt into surface

Results in ulcer formation

Angiopathy

Peripheral arterial disease (PAD) is a contributing factor to the de

velopment of foot ulcers in up to 50% of cases.
Diabetic macroangiopathy is histologically similar to
non diabetic atherosclerosis but distributed in the
distal segments of the lower extremities.
(calf and foot arteries).

Angiopathy
Arterial calcification readily detectable on plain x ray with
constriction noted on angiography.
This compromises oxygen supply to the periphery.
Gas exchange is further compromised by marked thickening of the capillary
basement membrane a feature of diabetic microangiopathy
Cumulatively, this leads to occlusive arterial disease that results in

ischemia in the lower extremity and an increased risk of ulceration in diab

etic patients.

How to examine diabetic foot?

1) LOOK
Neuropathic skin changes
) Dry skin, callosities, skin cracks/fissures
) Hair loss (vasculopathy)
) Ulcers and Gangrene
) Obvious deformities e.g.
Clawing of toes, Charcots joints (Later stage)
Infections
(e.g Cellulitis Erythema,
Inter digital spaces Tinea Pedis)
Nails:
Paronychia, Brown dystrophic nails (in later
stages)

Charcot Foot
The Charcot arthropathy is another common
deformity found in some affected diabetic.
It is the result of a combination of motor,
autonomic, and sensory neuropathies in which
there is muscle and joint laxity that lead to
changes in the arches of the foot.
Often collapse of midfoot arch
(aka. Rocker bottom foot)

Classification - Wagner
The results of the foot evaluation should aid in developing an
appropriate managemenTThese classification systems are based on a
variety of physical findings.

Grade 0 - No ulceration in a high risk foot

Grade 1 - Superficial ulcer
Grade 2 - Deep ulcer up to tendon, ligament, deep fascia, bone o
r joint.
Grade 3 - Deep ulcer with osteomyelitis or deep abscesses.
Grade 4 Limited or localized gangrene of toes or forefoot
Grade 5 Extensive gangrene of entire foot requires major amput
ation.

Wagner grade 0
Grade 0 - No ulceration in a high risk foot

Wagner grade 1
Grade 1 - Superficial ulcer

Wagner grade 2
Grade 2 - Deep ulcer up
to tendon, ligament, deep
fascia, bone or joint.

Wagner grade 3

Grade 3 - Deep ulcer with

osteomyelitis or deep abscesses.

Wagner grade 4
Grade 4 Limited or
localized gangrene of
toes or forefoot

Wagner grade 5
Grade 5
Extensive
gangrene of entire
foot requires major
amputation.

2) FEEL

Examination

Warmth
Tenderness (Features of Inflammation)
Dryness of skin

Pulses:

Dorsalis Pedis and Posterior Tibial Artery

(If poorly felt/not felt Do ABSI.
Claudication, loss of hair, and the presence of pale, thin, shiny, or cool skin are
findings suggestive of potential ischemia. ABSI can be used for determining the
extent
of vascular disease.

Normal range is from 0.9-1.2,

0.6-0.9 = Moderate risk
<0.6 is Marked risk of vascular foot ulceration.

2) FEEL

Examination

Sensation

Pain (toothpick)
Light touch (Cotton wool)

Check the sensory level (Glove and Stocking

sensory loss)
Proceed to check from distal to proximal.

type

Examination
10-gauge
Monofilament
The loss of pressure sensation in the
foot has
been identified as a significant
predictive factorfor the likelihood of
ulceration.

considered
reflective of an ulcer risk
The test is

if the patient is unable to sense

the monofilament when it is pressed
against

Examination
It is tested on various sites along
the
plantar aspect of the toes, the ball
of the
foot, and between the great and
second
toe.
The person who cannot feel at
least
7 of 10 pedal sites
tested is considered to have an
absent protective threshold

Examination
3) MOVE
Proprioception Joint position sensation

Diabetic Foot Ulcer Treatment

One of the most valuable strategies for managing
the diabetic foot is to prevent the development
of foot complications
since neuropathic foot ulceration can often lead
to complication
loss of a
Once a diabetic foot
has
limb
to a major amputation.
developed,
thedue
next
best strategy is to treat this complication early in a
hospital setting by a multidisciplinary diabetic foot
OBJECTIVE:
The objective of early and efficacious
team.
treatment is to achieve limb salvage in order to
avoid the loss of a limb
from a major amputation.

TREATMENT Modalities
1.
2.
3.
4.

Debridement
Offloading
Infection Control
Wound Care

Diabetic foot ulcer treatment

1) Debridement

Amainstayofulcertherapyisdebridementofallnecrotic, callus, and fibro

us tissue. Unhealthytissuemustbesharplydebridedbacktobleeding tiss
ue.

Thedebridementofthewoundwillincludetheremovalofsurroundingcallus
andwillaidindecreasingpressurepointsatcallusedsitesonthefoot.Additi
onally,theremovalofunhealthytissuecanaidinremovingcolonizingbacter
iainthewound.

Prompt and aggressive treatmentofdiabeticfootulcerscanoftenprevent

exacerbationoftheproblemandeliminate the potential for amputation.

Diabetic foot ulcer treatment

2) Offloading

Offloadinganddebridementareconsideredvitaltothehealingprocessford
iabeticfootwounds.

Thegoalofoffloadingistoredistribute force from ulcers sites and press

ure pointsatrisktoawiderareaofcontact.

Therearemultiplemethodsofpressurerelief,includingtotalcontactcastin
g,halfshoes,removablecastwalkers,wheelchairs,andcrutches.

Diabetic foot ulcer treatment

3) Wound Management

Anidealdressingshouldcontributetoamoist wound environment,absor

bexcessiveexudates,andnotincreasetheriskforinfections.

Dressingchangesandwoundinspectionshouldoccuronadailybasis.

Eg.Foam and alginate dressings are highly absorbent and can aid in decr
easing the risk for maceration in wounds with heavy exudates.

Diabetic foot ulcer treatment

4) Infection Control

Gram-positive cocci, Staph Aureus are typically the most common pat
hogens isolated.

However, chronic or previously treated wounds often show polymicr

obial growth, including gram-negative rods or anaerobes. Pseudomo
nas often in wounds treated with hydrotherapy or wet dressings

The selection of appropriate antimicrobial therapy, route of administr

ation, and need for inpatient or outpatient treatment will be determi
ned in part by the severity of the infection.

Diagnosis
Clinical presentation
Presence of purulence
Pain, swelling, ulceration, sinus tract formation, cre
pitation
Systemic infection (fever, rigors, vomiting, tachycar
dia, change in mental status, malaise)
Patients with systemic signs of severe infection should be admitt
ed for supportive care and intravenous antibiotic therapy. In the
absence of serious signs, patients can be treated with outpatient
therapy and frequent follow-up

Approach to diabetic foot ulcer

According to ulcer stage
0 At-risk foot, no ulceration : Patient education, ac
commodative footwear, regular clinical examina
tion
1 Superficial ulceration, not infected :Offloading w
ith total contact cast (TCC), walking brace, or sp
ecial footwear
2 Deep ulceration exposing tendons or joints : Sur
gical debridement, wound care, offloading, cult
ure-specific antibiotics
3 Extensive ulceration or abscess : Debridement or

Preventative foot care

The situation can be changed & possibly
reduce amputation rates between 50% -85% by:
Podiatry-Regularinspectionofthefoot,appropriatenailcare,warm(32 oC)soaks,moi
sturizingcreams,earlydetectionofnewlesions

Appropriate footwear wellcushionedsneakers,custommoldedshoes

Pressure reduction Pressure relief using total contact casts, removable cast walker
s, or half shoes is the mainstay of initial treatment. Cushionedinsoles,customorthos
es.

Patient education needfordailyinspectionandnecessityforearlyintervention,avoi

danceofbarefootwalking,improvingglycemiccontrolmayaidineradicatingtheinfectio
nandhealingthewound.

Physician education significanceoffootlesions,importanceofregularfootexaminat

ion.

Amputation in Diabetic Patient

Amputation is needed :
*Gangrene/Uncontrollableinfectionorsepsis
*Aspartofdebridement
*Forcorrectionoffootdeformities-Electivesurgerytocorrectstructuraldefor
mitiesthatcannotbeaccommodatedbytherapeuticfootwearcanbeperformedasneede
dincertainpatients.

The level of infection and viable skin should dictate the level of amputation.
The aim should be to salvage the maximum amount of proximal toe, up to t
he base of the proximal phalanx.
Eg. A ray amputation is necessary if necrosis has spread through the base of
the toes.

References

Clayton, W. and T. A. Elasy. "A Review Of The Pathophysiology, Classific

ation, And Treatment Of Foot Ulcers In Diabetic Patients". Clinical Diabet
es 27.2 (2009): 52-58.

Pendsey, SharadP. "Understanding Diabetic Foot". International Journal

of Diabetes in Developing Countries 30.2 (2010): 75.

Solomon, Louis, David Warwick, and Selvadurai Nayagam. Apley's Syste

m Of Orthopaedics And Fractures. London: Arnold, 2010. Print. Pg. 632,
Chapter 21.

"Surgical Management Of The Diabetic Foot". Medscape. N.p., 2016. W

eb. 16 Aug. 2016.