The Infected Foot Ulcer

Invasion of foot tissues by microorganisms, usually accompanied by an inflammatory response, may follow colonization of the skin by initially harmless bacteria, or occur as a primary event. Diagnosing a foot ulcer infection is based on clinical criteria. A superficial or a full-thickness ulcer, treated inadequately, predisposes to infection, although cellulitis or osteomyelitis can occur without a break in the skin. Infected ulcers are often asymptomatic, especially if the patient feels no...

Neuropathic Ulcer With Osteomyelitis

Debridement Under Feet

A 57-year-old obese male patient with type 2 diabetes diagnosed at the age of 40 years was referred to the outpatient diabetic foot clinic because of a chronic ulcer under his right foot. He was being treated with insulin and metformin with acceptable diabetes control HBA 7.8 . He had a history of background retinopathy and cataract in both eyes. He reported a severe deep tissue infection 5 years earlier after a burn sustained under his right foot. At that time he was hospitalized for about 1...

Extensive Wet Gangrene Of The Foot

Diabetic Foot Infection Necrosis

A 51-year-old male patient with type 1 diabetes diagnosed at the age of 25 years was admitted to the Vascular Surgery Department because of extremely painful wet gangrene on his right foot. The patient had proliferative diabetic retinopathy which had been treated with laser, significant loss of his visual acuity 3 10 in both eyes , hypertension and diabetic nephropathy. He had lived in a nursing home. His diabetes control was good HBAic 7 . The patient had complained of pain in his right foot...

Osteomyelitis

2nd Toe Sloughy Ulcer

A 69-year-old female patient with type 2 diabetes diagnosed at the age of 54 years and treated with sulfonylurea, was referred to the outpatient diabetic foot clinic for an infection of her right second toe. She had background diabetic retinopathy and hypertension. She complained of numbness and a sensation of pins and needles in her feet at night. On examination, she had findings of severe neuropathy no feeling of light touch, pain, temperature, vibration or a 5.08 monofilament Achilles tendon...

Pes Planus Flat Foot

A 73-year-old female patient with type 2 diabetes diagnosed at the age of 55 years and treated with insulin since the age of 65 years, attended the diabetic foot clinic because of a small superficial painful ulcer over her medial malleolus. The patient complained of dysesthesias she had a cold or warm sensation in her feet , and she had hypertension for which she had been treated with enalapril since the age of 55 years. The ulcer was noticed 4 weeks previously and had been caused by an...

New Treatments

There have been no controlled trials comparing the use of hyperbaric oxygen therapy Table 2.6 Properties, and indications of available dressings of Necrosis Gangre- Low High with low with high without dressing slough nous Infection exudate exudate exudate exudates sinus Table 2.7 Advantages and disadvantages of available types of dressings Table 2.7 Advantages and disadvantages of available types of dressings Traditional dressings gauze and absorbent cellulose Cheap and widely available....

Bunionette Tailors Bunion

A 54-year-old female diabetic patient attended the outpatient diabetic foot clinic for regular chiropody treatment. She had severe diabetic neuropathy with reduced sensation of light touch, vibration, pain, temperature and 5.07 monofilaments. Peripheral pulses were normal. Muscle atrophy of the feet, claw toes, mild hallux valgus, varus deformity of the lesser toes, and an exostosis of the lateral part of the fifth metatarsal head bunionette, Figure 3.5 were present. Another exostosis was noted...

Bone Scintigraphy Imaging

Callus Under Right Foot Pictures

The scintigraphy findings of a patient with possible osteomyelitis are discussed below and the history of this patient is illustrated in Figures 9.3 to 9.5 in Chapter 9. A plain radiograph showed findings compatible with osteomyelitis or neuro-osteoarthropathy of the second and third Figure 8.34 Full-thickness chronic neuropathic ulcer with gross callus formation under the right fifth metatarsal head Figure 8.34 Full-thickness chronic neuropathic ulcer with gross callus formation under the...

Pes Cavus

Shoes For Pes Cavus

A 64-year-old female patient with type 2 diabetes diagnosed at the age of 62 years was referred to the outpatient diabetic foot Figure 3.3 Pes planus with bunionette. Dorsal aspect Figure 3.3 Pes planus with bunionette. Dorsal aspect clinic for foot care. She had been treated with insulin for the last 4 years. The patient had a history of hypertension. No diabetic complications were mentioned. On examination, peripheral pulses were bounding. she had severe peripheral neuropathy no sensation of...

Pes Planus Deformity Bunionette

Flatfoot Pes Planus

A 74-year-old male patient with type 2 diabetes diagnosed at the age of 61 years attended the outpatient diabetic foot clinic for chiropody treatment. On examination, he was found to have mild callus formation at the plantar and the lateral area of the fifth metatarsal head Figures 3.2 and 3.3 . Bilateral pes planus flat foot deformity of his feet and a bony prominence at the lateral aspect of the fifth metatarsal head a bunionette or tailor's bunion were also found see Figure 3.2 . Blackening...

Claw And Curly Toe Deformities

Curly Toes Adults

A 68-year-old female patient with type 2 diabetes attended the outpatient diabetes clinic for her usual follow-up. On examination, she had severe diabetic neuropathy and palpable peripheral pulses. Claw toe deformity of her left second and third toes was noticed, as well as a curly fourth toe Figure 3.8 . Subungual hemorrhage and ingrown hallux nail, and hemorrhagic calluses of the second and third toes were also present. A hammer deformity was seen on the second toe of her right foot....

Wet Gangrene Of The Foot

Angiography Stenosis Superficial Femoral

Gangrene complicated with infection wet gangrene in a patient with longstanding type 2 diabetes. Redness and edema, due to infection, extended up to the lower third of the tibia Figure 7.23 . In this patient a below-knee amputation was necessary. Figure 7.17 Digital subtraction angiography of the foot illustrated in Figure 7.16, showing multiple sites of stenosis in right superficial femoral artery. Courtesy of C. Liapis Figure 7.18 Digital subtraction angiography of the foot shown in Figures...

Osteomyelitis Of The Heel

Bone Scan Phase Osteomyelitis

A 71-year-old female patient with type 2 diabetes was admitted to the hospital Figure 8.35 Anteroposterior plain radiograph of patient of Figure 8.34. Osteomyelitis. Pseu-doarthrosis of a stress fracture of the upper third of the fifth metatarsal, bone resorption at the metatarsophalangeal joint, and osteolytic lesions at the fifth metatarsal epiphysis Figure 8.35 Anteroposterior plain radiograph of patient of Figure 8.34. Osteomyelitis. Pseu-doarthrosis of a stress fracture of the upper third...

Diffuse Osteopenia In The Foot

Third Toe Ulcers Photos

Figure 5.4 Neuropathic ulcer over a bony prominence in a patient with neuro-osteoarth-ropathy Figure 5.4 Neuropathic ulcer over a bony prominence in a patient with neuro-osteoarth-ropathy its base is clean, covered by healthy granulating tissue. Therapeutic footwear was prescribed extra depth shoes with an orthotic insole and a window under the ulcerated area and the patient was advised to minimize his activities. The ulcer healed in 3 months. Ulcers in patients with midfoot collapse recur very...

Gangrene Pictures

Wet Gangrene

Figure 7.22 Digital subtraction angiography of the foot shown in Figure 7.21. Multifocal atheromatous lesions of both iliac and superficial femoral arteries and increased development of collateral vessels can be seen. This pattern of arterial obstruction is considered typical in diabetes. Courtesy of E. Bastounis admission the pain worsened progressively and had become refractory to analgesics in the last 2 days. He denied any trauma to his feet. The patient had fever 38.7 C with rigors and...

Prevention Of Foot Ulcers

Neuro Ischemic Ulceration

Based on the results of clinical examination, and or laboratory testing and imaging studies, every patient with diabetes may be classified on the basis of the risk for foot problems Table 2.5 . This classification helps as a guide for patient management. Patients with active foot ulcers are not included in this classification. Inappropriate footwear is a major cause of ulceration. The aim of providing special shoes and insoles preventive foot wear to diabetic patients at risk for foot...

Fungal Infection With Multimicrobial Colonization

Diabetic Foot Infection

Superficial ulcers of 10 days' duration on the facing sides of the left first and second toe of a 70-year-old type 2 diabetic lady with diabetic neuropathy, before debridement are shown in Figures 8.8 and 8.9. Note soaking of the skin. An X-ray excluded osteomyelitis. Staphylococcus coagulase-negative, Pseudomonas aerugi-nosa and enterobacteriaceae were recovered after swab cultures in addition to Candida albicans. She was treated successfully with itraconazole for 5 weeks. The patient used a...

Wet Gangrene Leading To Midtarsal Disarticulation

Piperacillin With Clavulanic Acid

A 70-year-old male patient who had type 2 diabetes since the age of 58 years was referred to the outpatient diabetic foot clinic because of wet gangrene of his left foot. He was treated with insulin but his diabetes control was poor. He had hypertension, background diabetic retinopathy and he was a current smoker. The patient noticed black areas on the toes of his foot 7 days previously, but he continued his daily activities since he felt only mild pain. On examination, he was feverless and his...

Neuroischemic Ulcers At Various Sites

Foot Booties For Pressure Ulcers

Neuro-Ischemic Ulcer with Osteomyelitis Neuro-Ischemic Ulcer on the Hallux with Osteomyelitis A 68-year-old obese male patient with type 2 diabetes diagnosed at the age of 46 years visited the outpatient diabetic foot clinic because of two chronic ulcers on his right hallux. He was treated with a combination of sulfonylurea during the day and a mixture of 20 rapid acting-80 intermediate acting insulin before dinner he also had dislipidemia which was being treated with simvastatin. On...

Some Uncommon Conditions

Ulcerated Gout Shin

Calcium Pyrophosphate Dihydrate CPPD Deposition Disease A 75-year-old male patient with type 2 diabetes diagnosed at the age of 64 years was referred to the foot clinic for foot care. He was a psychiatric patient treated on an outpatient basis. The patient had findings of peripheral neuropathy with loss of sensation of pain, light touch, vibration and temperature. Peripheral pulses were palpable. Claw toes and extreme onychogryposis was noted Figure 4.1 . His nails were cut using a special nail...

Callus On Tip Of

Fifth Ray Amputation

In the case of claw toe deformity of the second toe, callus formation and onychodys-trophy was due to exposure of the tip of the toe to high pressure during the propulsion phase of gait. A purulent discharge was evident after removal of the callus Figure 8.1 . The patient felt no pain or discomfort due to severe peripheral neuropathy. No other signs of infection were present on the toe or the forefoot, therefore drainage of pus was adequate, and no further treatment was needed. Appropriate...

Stints For Toes

Ischemic Ulcer

A 71-year-old male patient was admitted because of gangrene in his left foot. Diabetes mellitus was diagnosed on admission and he was treated with low doses of insulin. Antibiotic therapy was initiated, in addition to pentoxyphillin, prostaglandin E1 synthetic analog and phentanyl for the pain. A digital subtraction angiography was carried out which disclosed multiple sites of stenosis in both iliac and superficial femoral arteries Figure 7.16 upper panel, and Figure 7.17 . A suboptimal...

Varus Deformity Of Toes

Curly Fourth Toe

In varus deformity of toes the third, fourth and fifth toes drift medially. The nails of Figure 3.10 Curly fourth toe. Note inward malrotation Figure 3.10 Curly fourth toe. Note inward malrotation the toes may cause superficial ulcers on the adjacent toes. This patient was a 60-year-old female with type 2 diabetes diagnosed at the age of 51 years. She had severe diabetic neuropathy peripheral pulses were normal, and she had never had a foot ulcer. In addition to varus deformity, clawing of her...

Chronic Neuropathic Ulcer With Osteomyelitis

Diabetic Foot Osteomyelitis

A 46-year-old male patient with type 1 diabetes diagnosed at the age of 27 years was referred to the outpatient diabetes foot clinic because of a chronic ulcer under his right fifth metatarsal head. He had acceptable diabetes control HBA1c 7.7 , pro-liferative diabetic retinopathy treated with laser in both eyes, but no nephropathy. He complained of muscle cramps during the night and chronic constipation interrupted by episodes of nocturnal diarrhea. The patient had a history of painless...

Soft Tissue Infection

Treatment Blisters Under Callus

A 58-year-old male patient with type 2 diabetes, diagnosed at the age of 45 years, attended the outpatient diabetic foot clinic for chiropody treatment on a fortnightly basis. He had severe peripheral neuropathy, claw toe deformity and prominent metatarsal heads. He mentioned mild pain on his left midsole on finding a coin in his shoe after prolonged walking. On examination, he had a lax blister containing purulent fluid under his left midsole. There was extensive surrounding erythema and...

Bibliography Of Diabetic Mellitus Foot Care

Surgical management of the diabetic foot. Br J Hosp Med 1976 16 227-232. 2. Wagner FW. The dysvascular foot a system for diagnosis and treatment. Foot Ankle 1981 2 64. 3. Lavery LA, Armstrong DG, Harkless LB. Classification of diabetic foot wounds. J Foot Ankle Surg 1996 35 528-531. 4. Armstrong DG, Lavery LA, Harkless LB. Validation of a diabetic wound classification system. Diabetes Care 1998 21 855-861. 5. Consensus development conference on diabetic foot wound care. Diabetes...

Infected Plantar Ulcer With Osteomyelitis

Minor Infected Toe

A 50-year-old female diabetic patient with type 2 diabetes diagnosed at the age of 44 years and treated with sulfonylurea, was referred to the outpatient diabetic foot clinic because of a chronic infected ulcer on her left foot. The patient lived alone and she was being treated for depression she had good diabetes control. A minor trauma under her left foot was reported to have occurred 2 years previously. She had treated the injury with different types of gauzes and creams, but it failed to...

Dry Gangrene Of Heel

Diabetic Foot Pressure Sores

A 74-year-old female patient with longstanding type 2 diabetes was admitted to the hospital because of a stroke. She had palsy of her left arm and foot. Her hos-pitalization was complicated by aspiration pneumonia, which confined the patient to bed for 2 weeks. The patient had a history of ischemic heart disease and hypertension. peripheral pulses were weak in both feet. on the sixth day of her hospitalization a blister with a black base developed on the posterolateral aspect of her left foot,...

Dry Gangrene With Ischemic Necrosis Of The Skin

Gangrene Ankle

Dry gangrene in a female patient with type 2 diabetes, involving the distal parts of the toes of her right foot is illustrated in Figure 7.2. The pedal arteries were not palpable and the ankle brachial index was 0.4. A well-demarcated red area extended up to the ankle and the lateral foot, indicating ischemic necrosis of the skin. Angiogra-phy showed the patient to have multilevel severe atherosclerotic disease with involvement of the tibial and pedal arteries. An attempt at mid-tarsal at...

Diabetic Neuropathy

Pathway Diabetic Ulcer

Diabetic neuropathy is defined according to the International Consensus Group on Neuropathy as 'the presence of symptoms and or signs of peripheral nerve dysfunction in people with diabetes, after exclusion of other causes'. The prevalence of peripheral neuropathy in diabetes is 23-42 and is higher 50-60 among older type 2 diabetic patients. It should be mentioned that the prevalence of symptomatic peripheral neuropathy burning sensation, pins and needles or allodynia in the feet, shooting,...

Onychomycosis

Chronic Onychomycosis

The patient whose feet are shown in Figures 5.12-5.16 was suffering from onychomycosis and the nails and nail beds were completely destroyed by fungus as shown in Figure 8.7. Onychomycosis per se does not cause foot problems, but when it affects the proximal nail proximal subungual onychomycosis it may cause chronic paronychia and serve as a portal for bacteria, resulting in deep tissue infection. It often co-exists with mycosis of the web spaces and it may be superinfected by bacteria, leading...

Methods For Offloading Pressure On The Foot

Scotchcast Boot

The mainstay in the management of an active plantar foot ulcer is the effective offloading of the ulcer area. Once an ulcer is Figure 2.12 Lower side of insole illustrated in Figure 2.11 Figure 2.12 Lower side of insole illustrated in Figure 2.11 present, it will not heal unless the mechanical load on it is removed. Among the methods used for this purpose are complete bed rest, crutch-assisted gait, wheelchair, and prosthetics. However, these methods are impractical for the majority of patients...

Heloma Durum Bunion Bursitis Claw

Heloma Dura Image

A 67-year-old male patient with type 2 diabetes attended the outpatient diabetic foot Figure 3.11 Varus and claw toes deformity clinic because he had developed painless hyperkeratosis on the dorsum of his toes. He had severe peripheral sensorimotor neuropathy peripheral pulses were normal. Significant muscle atrophy was seen on the dorsum of his feet Figure 3.12 . Mild hallux valgus and claw toes deformity were also present. As a result of a bunion see below due to hallux valgus deformity, a...

Wet Gangrene Of The Hallux

Superficial Femoral Artery Stenosis

A 72-year-old male patient with type 2 diabetes diagnosed at the age of 60 years and being treated with insulin, attended the outpatient diabetic foot clinic because of pain in his right hallux. His diabetes control was poor HBA1c 8.7 . He had hypertension and background retinopathy in both eyes. He was an ex-smoker. The patient had Figure 7.28 Wet gangrene of the right hallux and claw toe deformity. Ischemic hair, redness over toes, dystrophic nail changes can also be seen Figure 7.28 Wet...

Peripheral Vascular Disease

Peripheral Artery Disease Tcpo2

ASSESSMENT OF THE VASCULAR STATUS IN PATIENTS WITH DIABETES The prevalence of peripheral vascular disease in diabetic patients is 15-30 . The Figure 1.4 Examination of vibration perception by the use of a biothesiometer Figure 1.4 Examination of vibration perception by the use of a biothesiometer disease progresses with both duration of diabetes and age. A diagnostic work-up of the peripheral extremities is based on clinical examination history of intermittent claudication, rest pain, walking...

Gangrene

Necrotic Toes

Dry Gangrene with Ischemic Necrosis OF THE Skin Wet Gangrene Leading to Mid-Tarsal Disarticulation A 65-year-old male patient with type 2 diabetes diagnosed at the age of 61 years and treated with sulfonylurea, was admitted to the Vascular Surgery Department. He was a heavy smoker and had a sedentary lifestyle. He had hypertension, background diabetic retinopathy and dyslipidemia triglycerides 4 mmol l HDL-cholesterol 0.67 mmol l . His diabetes control was poor HBA1c 8.5 . The patient...

Shoes With Toes

Mild Superficial Diabetic Ulcer

A mallet toe consists of plantar flexion of the distal interphalangeal, and neutral position of metatarsophalangeal and proximal interphalangeal joints Figure 3.26 . Toe deformities hammer, claw, curly, mallet toe and overriding of toes are unknown in non-shoe wearing populations. Their incidence varies from 2 to 20 , and increases with age. Women are affected four to five times more often than men. Most people have no underlying disease, although neuromuscular diseases and inflammatory...

Claw Toes

Muscle Atrophy Foot

A 56-year-old male patient with type 2 diabetes diagnosed at the age of 44 years attended the outpatient diabetes clinic. He had been treated with insulin since the age of 53 years, with excellent results HBA1c 6.7 . He had background diabetic retinopathy. Figure 3.6 Muscle atrophy with claw toes and hallux valgus Figure 3.6 Muscle atrophy with claw toes and hallux valgus On examination, the patient had severe diabetic neuropathy with complete loss of sensation of pain, light touch and...

Classification Systems

Stage Iii Metatarsal Head Pressure Ulcer

The Meggitt-Wagner classification is the most well-known and validated system for foot ulcers, and is shown in Table 2.1. The advantages and disadvantages of this classification system are described in Table 2.2. 'The University of Texas classification system for diabetic foot wounds', Table 2.1 Meggitt-Wagner classification of foot ulcers Table 2.1 Meggitt-Wagner classification of foot ulcers Table 2.2 Advantages and disadvantages of the Meggitt-Wagner classification system It is simple to...

Web Space Infection

Web Space Infection

A 72-year-old female patient with type 2 diabetes diagnosed at the age of 61 years, was referred to the outpatient diabetic foot clinic because of an infection in her left foot. The patient had poor diabetes control HBA1c 8.5 , and was being treated with insulin twice daily. She had background Figure 8.4 Objects collected from patients' shoes. Loss of protective sensation prevents patients from feeling injurious stimuli Figure 8.4 Objects collected from patients' shoes. Loss of protective...

Osteomyelitis Of The Hallux

Osteolytic Toe

A 30-year-old male patient with type 1 diabetes diagnosed at the age of 11 years was admitted because of infected foot ulcers on his right hallux. He had a mild fever and a history of proliferative diabetic retinopa-thy and microalbuminuria. Diabetes control was poor HBA1c 9.5 . He reported a trauma to his left foot 2 months earlier when an object fell on his feet while working. A superficial ulcer had developed on the dorsal aspect of his right great toe the ulcer had become infected because...

Convex Triangular Foot Hallux Valgus And Quintus Varus

Over Riding Fifth Toe

A 48-year-old female diabetic patient with type 2 diabetes diagnosed 6 months before her first visit, and treated with sulfonylurea, was referred to the outpatient diabetic foot clinic because of an ulcer on her right foot. The diabetes had been adequately controlled but the patient was already exhibiting signs of diabetic complications, such as background retinopathy and neuropathy. On examination, she had a right convex triangular foot, with an ulcer under the head of the fifth metatarsal...

Wet Gangrene And Sepsis

Ischemic Ulcer

A 65-year-old male patient who had type 2 diabetes since the age of 45 years and was being treated with sulfonylureas, was brought to the emergency clinic suffering from a fever. He had left paraplegia following a stroke 6 months earlier. One month before admission the toes of his left foot became gradually very painful Figure 7.5 Calf support device which provides a larger resting surface thus offloading pressure from the heel Figure 7.5 Calf support device which provides a larger resting...

Onychomycosis Hallux Valgus And Hammer Toe Deformity

Hallux Valgus And Rigid Hammer Toe

A 68-year-old female patient with diabetes diagnosed at the age of 50 years and treated with insulin, was referred to the outpatient diabetic foot clinic because of foot deformities and recurrent superficial toe ulcers. The patient had findings of peripheral neuropathy. Peripheral pulses were palpable. No other diabetic complications were present. Onychomycosis was noticed and confirmed by direct microscopic examination of nail specimens. The skin on her feet was dry hallux valgus and hammer...

Hallux Valgus Overriding Toe Claw Toes Edema

Plantar Hallux Ulcer

A 68-year-old female patient with type 2 diabetes diagnosed at the age of 45 years attended the outpatient diabetic foot clinic Figure 3.17 Extra-depth shoes and custom insoles for routine chiropody treatment. She was being treated with insulin. The patient had hypertension, advanced background retinopathy which had been treated with laser in both eyes, and diabetic nephropa-thy urine protein 2.6 g 24 h . On examination, she had severe diabetic neuropathy and gross ankle edema due to...

Phlegmon

Subcutaneous Foot Mass

A 62-year-old male diabetic patient with type 2 diabetes diagnosed at the age of 42 years and treated with sulfonylurea, biguanide and acarbose and whose diabetes control was acceptable, visited the outpatient diabetic foot clinic due to infection of the sole of his right foot. He had hypertension and coronary heart disease treated with metoprolol and aspirin. He had no previous history of foot problems. On examination, the patient had fever, severe diabetic neuropathy, and bounding pedal...

Prominent Metatarsal Heads And Claw Toes

A 65-year-old male patient with longstanding type 2 diabetes attended the outpatient diabetic foot clinic for callus removal and treatment of ulcers on the tip of his second and fifth right toes Figure 3.27 . On examination, he had bounding pedal pulses, and severe peripheral neuropathy. Metatarsal heads were prominent, and claw toes were present. Claw toe deformities may cause prominence of metatarsal heads with subsequent Figure 3.27 Prominent metatarsal heads and claw toes callus formation...

Heloma Molle

A 54-year-old male patient with type 2 diabetes diagnosed at the age of 48 years attended the outpatient diabetic foot clinic for callus removal. He had severe diabetic neuropathy loss of sensation of pain, light touch, temperature, vibration and 5.07 monofilaments , and he complained of mild pain on his left little toe. On examination, a painful corn was seen at the medial aspect of his left little toe Figure 3.13 . Corns are circular hyperkeratotic areas which may be soft or hard. They have a...