An 80-year-old woman with type 2 diabetes mellitus was admitted to hospital following a stroke and discharged home under the care of the general practitioner. The right foot became discoloured but she felt no pain and it was not until overwhelming necrosis of the right foot and
lower limb had developed that she showed her leg to the district nurses (Fig. 7.2). When she was admitted to hospital she was moribund. She had necrosis spreading to the lower leg which was icy cold. Clinically, this indicated a major arterial occlusion. She underwent palliative care and died shortly afterwards.
• If neuropathy is profound even occlusion of a major vessel will not be painful.
• Patients who have had a stroke may have abnormal sensations and fail to complain.
• Vulnerable patients in the community should have their feet checked regularly by health-care professionals.
Major amputation in a neuropathic foot should be a very rare event and necessary only when:
• Infection has irretrievably destroyed the foot
• Charcot's osteoarthropathy has destroyed the ankle joint, attempts at external stabilization have been unsuccessful and internal fixation is not possible.
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