Info

Previous ulcer

Once every 1-3 months

IDF risk categorisation system (Table 14.1 and Box 14.3). This can be used to determine the appropriate frequency of further examinations. Patient education should be offered at every routine check (Boxes 14.4,14.5 and 14.6).

Box 14.3 IDF risk factors

Previous ulcer/amputation Lack of social contact Lack of education

Impaired protective sensation (monofilaments) Impaired vibration perception Absent Achilles tendon reflex Callus

Foot deformities Inappropriate footwear

Box 14.4 International Diabetes Federation: Five cornerstones of the management of the diabetic foot

Regular inspection and examination of the foot at risk

Identification of the foot at risk

Education of patient, family and healthcare providers

Appropriate footwear

Treatment of non-ulcerative pathology

From Diabetes/Metabolism Research and Reviews 2008;24(Suppl. 1):S181-7

Box 14.5 Common triggers for ulceration

Poorly fitting footwear Unnoticed trauma from foreign body Burns (hot bath, hot water bottle, radiator) Heel friction in a patient confined to bed Nail infection Dry skin

Self-treatment of callus with sharp instruments, or corn plasters Callus not effectively treated

Box 14.6 Patient education and routine foot care

Diabetic foot ulcers are extremely preventable if the patient and carers are aware of the risks and take good care of the feet. Eighty per cent of ulcers are caused by trauma, often unnoticed due to neuropathy. Some common causes are listed in Box 14.5. Patients should be encouraged to:

• Wear comfortable, supportive footwear

• Avoid walking 'barefoot'

• Wash the feet once a day in warm (not hot) soapy water

• Check for problems every day and report any fissuring or other loss of skin integrity

• If the skin is dry, use a regular emollient to reduce risk of fissuring

• Never fail to remove a foreign body from the shoe immediately after it is noticed

• Do not warm the feet using hot water bottles or by direct contact with a radiator

• Never attempt to 'self-manage' callosities using sharp paring instruments

• Do not apply adherent dressings such as corn plasters to the feet

Charcot's joint

Loss of proprioceptive function leads to abnormal weight distribution in the ankle joint or the small joints of the foot. Initially this produces wearing and degeneration at the articular surfaces, but later the joint may become distorted and dysfunctional. The final stage of this process is a 'Charcot's joint', which is swollen and disfigured externally and disorganised internally. Reduced awareness of trauma together with disordered movements put the patient at high risk of pressure ulceration particularly if footwear is not adequate. The internal arch of the foot falls and ulceration at this site is common (Figure 14.6).

Treatment of diabetic foot complications Importance of early referral

Once a problem is identified the patient must access the necessary expertise for energetic treatment and follow-up. This will usually involve a specialist foot clinic and all primary care clinicians must be clear regarding referral pathways. The foot clinic may be community-basedbut should have close links with surgical facilities.

Figure 14.6 Classic Charcot's mid-foot ulcer following collapse of the foot arches.

A major cause of ulcers failing to heal is delay in starting appropriate treatment including debridement, by which time infection that might have been treated conservatively has penetrated the deeper tissues, causing necrosis and threatening the viability of the limb. Treatment options listed include both conservative and surgical approaches (Box 14.7).

Box 14.7 Summary of treatment options for an infected diabetic foot ulcer

Conservative

Antibiotics for infection Topical wound management Desloughing of ulcer base Appropriate footwear

A walking programme (if no ulcer or gangrene) Pressure relief cast Smoking cessation

Control of vascular risk (blood pressure, glycaemia, lipids, low-dose aspirin)

Glycaemic control Nutritional management

Surgical

Debridement of necrotic tissue Drainage of foot abscess Revascularisation Amputation

All patients with successfully healed ulcers must be followed up indefinitely as 'high risk'

Is the ulcer infected and if so, how severely?

The first decision is over whether or not a foot ulcer or wound is infected (Figure 14.7). Next, the depth and severity of infection must be assessed (Box 14.8). These answers will determine the need for antibiotics, the choice of antibiotic, the route of administration and setting in which they are given, and the need and timing of surgical

Figure 14.7 Neglected paronychia of the right great toenail with invasive infection and ulceration of proximal tissue.

Figure 14.8 Extensive spreading cellulitis from a distal area of superficial ulceration.

Figure 14.7 Neglected paronychia of the right great toenail with invasive infection and ulceration of proximal tissue.

Figure 14.8 Extensive spreading cellulitis from a distal area of superficial ulceration.

intervention if appropriate. In addition to clinical examination, x-rays to exclude underlying osteomyelitis and blood tests looking for leukocytosis or other inflammatory markers may be required. However, patients with diabetes may not produce the usual response to infection and the absence of raised inflammatory markers does not exclude infection.

Box 14.8 Signs of foot wound infection in diabetes

Local:

Systemic:

Radiographic:

Pain

Fever

Osteomyelitis on x-ray

Tenderness

Rigors

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