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DIABETIC FOOT
ULCER
BY:
DR. MOHD HAZIM BIN ABDULLAH
MEDICAL OFFICER, WOUND TEAM
HOSPITAL DUCHESS OF KENT, SANDAKAN
Wound Care Manual, First Edition 2014
INTRODUCTION
• Diabetic foot is a foot that exhibits any pathology that results directly from
diabetes mellitus or any long‐term (or "chronic") complication of diabetes
mellitus (Jeffcoate & Harding, 2003).
• Diabetic foot implies that the pathophysiological process of diabetes m
ellitus does something to the foot that puts it at increased risk for “tissue d
amage” and the resultant increase in morbidity and maybe amputation
(Payne & Florkowski, 1998).
INCIDENCE
• Studies have indicated that diabetic patients have up to a 25%
lifetime risk of developing a foot ulcer.
• The annual incidence of diabetic foot ulcers is ~ 3% to as high
as 10%. (Armstrong and Lavery, 1998)
RISK FACTORS
• History of ulceration
• Presence of neuropathy
• Presence of peripheral vascular disease
• Presence of foot deformity
• Inappropriate footwear
• Skin lesion
• Nail pathology
• Duration of diabetes
• Prolonged standing or walking
• Type of occupation
PATHOPHYSIOLOGY
• Neuropathy‐ leads to skin dryness and cracks, foot
deformity and loss of protective sense in the foot
• Microangiopathy/vascular disease‐ lead to poor blood
supply to the toes and foot and then ulcerate easily
• Immunopathy‐ Defects in leukocyte function (leukocyte
phagocytosis, neutrophil dysfunction) and also deficient w
hite cell chemotaxis and adherence
CLINICAL PRESENTATION
• Soft tissue infections (superficial to deep tissue infection e.g.
cellulitis, necrotizing fasciitis, etc.)
• Osteomyelitis (bone infection)
• Septic arthritis (joint infection)
• Gangrene (dry or wet)
• Chronic non‐healing ulcer
• Combination of more than one of the above mentioned condition
ASSESSMENT
•History
•Examination
HISTORY
• Diabetic history
• Previous ulcer or amputation
• Symptoms of peripheral neuropathy
• Symptoms of peripheral vascular/ischemic problem
• Contributing factors
• Other complications of diabetes (eyes, kidney, heart etc).
• Current ulcer
EXAMINATION
• Previous amputation/ulcer
• Deformity and footwear
• Inspect web spaces ‐ signs of infection or wound
• Hypercallosity or nail deformity or paronychia
• Present of peripheral neuropathy with tuning folks, also mono
filament and position sense.
• Peripheral pulses ‐ peripheral vascular disease
• Ankle‐brachial index (ABSI)
• Other relevant systems (renal, eye, heart etc)
Do not forget to
examine the
other foot!
CLASSIFICATION OF THE DIABETIC FOOT
- WAGNER CLASSIFICATION
MANAGEMENT
Objectives:
1. Control infection
2. Ulcer/wound management
3. Prevent amputation
4. Maintain pre‐morbid foot/lower extremity function as much as possible
5. Prevent recurrent ulcer
GENERAL MANAGEMENT
• A multidisciplinary approach
• Good diabetic control
• Systemic antibiotics (according to CPG on Antibiotic Guidel
ine and also culture and sensitivity of the infected tissue)
• Optimize other co‐morbid complications.
• Advise to stop smoking
LOCAL MANAGEMENT
• Wound/ulcer management: depending on severity of wound; vasc
ularity and also presence of infection.
• Debride infected/necrotic tissue follow by wound management (refer
Wound care Algorithm in Chapter 17)
• Do not hesitate to perform re‐debridement if indicated.
• Amputation may be the treatment of choice.
• Minimize risk of re‐infection
• If indicated reestablished adequate blood supply (refer to chapter on a
rterial ulcer).
• Off loading with contact cast etc
• Good foot care and foot wear If no signs of healing after 2 weeks of
treatment, reevaluate and looks for the cause.
DIABETIC FOOT-CARE
• Foot inspection‐ minimally once a day
• Use lukewarm (air suam), not hot water to
wash feet
• Use gentle soap to bath/wash feet •
Apply moisturizer to avoid dry feet –
be careful with the web space and
not too much (causing skin maceration)
• Proper nail cutting, avoid cutting too close
/digging nail fold.
• Wear clean, dry socks (NEVER use heating
pad or hot water bottle) to keep foot
warm
• Avoid walk barefooted.
• Wear comfortable well fitting shoe (not too tight
or too loose), evening is the best time to buy sho
e.
• Shake out shoes and feel the inside before
wearing
• Never treat corns or calluses themselves
• Good diabetic control
• Stop smoking
• Periodic foot examination by relevant personals
• Keep the blood flowing to feet (elevate, wiggers to
es, moving ankle) , avoid cross‐leg or hanging leg/
feet too long
TAKE HOME MESSAGES
• Good glycemic control, regular foot assessment; including vascular
and neurological assessment; to prevent diabetic foot ulcer.
• The main underlying cause of diabetic foot ulcer is chronic pressure
‐ think of off loading.
• Diabetic foot ulcer needs multidisciplinary approach
THANK YOU

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Diabetic foot ulcer

  • 1. DIABETIC FOOT ULCER BY: DR. MOHD HAZIM BIN ABDULLAH MEDICAL OFFICER, WOUND TEAM HOSPITAL DUCHESS OF KENT, SANDAKAN Wound Care Manual, First Edition 2014
  • 2. INTRODUCTION • Diabetic foot is a foot that exhibits any pathology that results directly from diabetes mellitus or any long‐term (or "chronic") complication of diabetes mellitus (Jeffcoate & Harding, 2003). • Diabetic foot implies that the pathophysiological process of diabetes m ellitus does something to the foot that puts it at increased risk for “tissue d amage” and the resultant increase in morbidity and maybe amputation (Payne & Florkowski, 1998).
  • 3. INCIDENCE • Studies have indicated that diabetic patients have up to a 25% lifetime risk of developing a foot ulcer. • The annual incidence of diabetic foot ulcers is ~ 3% to as high as 10%. (Armstrong and Lavery, 1998)
  • 4. RISK FACTORS • History of ulceration • Presence of neuropathy • Presence of peripheral vascular disease • Presence of foot deformity • Inappropriate footwear • Skin lesion • Nail pathology • Duration of diabetes • Prolonged standing or walking • Type of occupation
  • 5. PATHOPHYSIOLOGY • Neuropathy‐ leads to skin dryness and cracks, foot deformity and loss of protective sense in the foot • Microangiopathy/vascular disease‐ lead to poor blood supply to the toes and foot and then ulcerate easily • Immunopathy‐ Defects in leukocyte function (leukocyte phagocytosis, neutrophil dysfunction) and also deficient w hite cell chemotaxis and adherence
  • 6. CLINICAL PRESENTATION • Soft tissue infections (superficial to deep tissue infection e.g. cellulitis, necrotizing fasciitis, etc.) • Osteomyelitis (bone infection) • Septic arthritis (joint infection) • Gangrene (dry or wet) • Chronic non‐healing ulcer • Combination of more than one of the above mentioned condition
  • 8. HISTORY • Diabetic history • Previous ulcer or amputation • Symptoms of peripheral neuropathy • Symptoms of peripheral vascular/ischemic problem • Contributing factors • Other complications of diabetes (eyes, kidney, heart etc). • Current ulcer
  • 9. EXAMINATION • Previous amputation/ulcer • Deformity and footwear • Inspect web spaces ‐ signs of infection or wound • Hypercallosity or nail deformity or paronychia • Present of peripheral neuropathy with tuning folks, also mono filament and position sense. • Peripheral pulses ‐ peripheral vascular disease • Ankle‐brachial index (ABSI) • Other relevant systems (renal, eye, heart etc) Do not forget to examine the other foot!
  • 10. CLASSIFICATION OF THE DIABETIC FOOT - WAGNER CLASSIFICATION
  • 11.
  • 12.
  • 13. MANAGEMENT Objectives: 1. Control infection 2. Ulcer/wound management 3. Prevent amputation 4. Maintain pre‐morbid foot/lower extremity function as much as possible 5. Prevent recurrent ulcer
  • 14.
  • 15. GENERAL MANAGEMENT • A multidisciplinary approach • Good diabetic control • Systemic antibiotics (according to CPG on Antibiotic Guidel ine and also culture and sensitivity of the infected tissue) • Optimize other co‐morbid complications. • Advise to stop smoking
  • 16. LOCAL MANAGEMENT • Wound/ulcer management: depending on severity of wound; vasc ularity and also presence of infection. • Debride infected/necrotic tissue follow by wound management (refer Wound care Algorithm in Chapter 17) • Do not hesitate to perform re‐debridement if indicated. • Amputation may be the treatment of choice. • Minimize risk of re‐infection • If indicated reestablished adequate blood supply (refer to chapter on a rterial ulcer). • Off loading with contact cast etc • Good foot care and foot wear If no signs of healing after 2 weeks of treatment, reevaluate and looks for the cause.
  • 17. DIABETIC FOOT-CARE • Foot inspection‐ minimally once a day • Use lukewarm (air suam), not hot water to wash feet • Use gentle soap to bath/wash feet • Apply moisturizer to avoid dry feet – be careful with the web space and not too much (causing skin maceration) • Proper nail cutting, avoid cutting too close /digging nail fold. • Wear clean, dry socks (NEVER use heating pad or hot water bottle) to keep foot warm • Avoid walk barefooted. • Wear comfortable well fitting shoe (not too tight or too loose), evening is the best time to buy sho e. • Shake out shoes and feel the inside before wearing • Never treat corns or calluses themselves • Good diabetic control • Stop smoking • Periodic foot examination by relevant personals • Keep the blood flowing to feet (elevate, wiggers to es, moving ankle) , avoid cross‐leg or hanging leg/ feet too long
  • 18.
  • 19. TAKE HOME MESSAGES • Good glycemic control, regular foot assessment; including vascular and neurological assessment; to prevent diabetic foot ulcer. • The main underlying cause of diabetic foot ulcer is chronic pressure ‐ think of off loading. • Diabetic foot ulcer needs multidisciplinary approach