Diabetic foot ulcer

Diabetic foot ulcer

1. NUR FADZLINA ZABRI 082013100006 Diabetic foot ulcer

2. Introduction Any infection involving the foot in a person with diabetes originating in a chronic or acute injury to the soft tissues of the foot, with evidence of pre-existing neuropathy and/or ischemia

3. Risk factors Predisposition to peripheral vascular disease Damage to peripheral nerve Osteoporosis Reduced resistance to infection Male Diabetic >10 years Smoking Abnormal foot structure

4. Peripheral vascular disease commonly caused by Atherosclerosis – mainly affects the medium sized vessels below the knee Digital vessel occlusion  dry gangrene Proximal vessel occlusion  extensive wet gangrene

5. Patient complaints of claudication/ischemia changes/ulceration which is painful and tender

6. Peripheral neuropathy Loss of nerve fiber function in the peripheral nerve

7. On clinical test  Loss of vibration, joint position sense and diminished temperature discrimination in the feet. Symptom Sensory impairment Symmetrical numbness and paraesthesia Dryness and blistering of skin Superficial burns, cracking of skin/ulceration due to shoe scruff or localized pressure

8. Motor impairment  claw toe with high arch Excessive pressure on the metatarsal heads resulted in marked callus build-up that is further accelerated by the dry skin. The patient is at high risk for ulceration at these sites.

9. Callus formation at pressure points and dry skin are substrate for ulceration

10. Neuropathic joint disease Charcot neuroarthropathy – Progressive condition affecting bones and joint of foot Charcot joints occur less than 1% in diabetic patient Common site – mid tarsal joint, MTP, ankle joint Characterized by : Early inflammation Joint dislocation or subluxation Pathological fracture of foot deformity Rocker bottom deformity from collapse of the midfoot is diagnostic

11. Provocative incident(twisting injury or fracture)  joint collapses Xray finding – marked and fairly rapid destruction of the articular surface Can be mistaken for infection Simultaneous involvement of several small joints and lack of systemic signs

12. Wagner Classification for ulcer

13. 1 6 5 3 2 4

14. Patient’s evaluation

15. Investigation FBS/RBS Glycosylated hemoglobin (HbA1C) ESR Wound and Blood cultures Urinalysis Plain X-rays - Osteomyelitis , fractures - Soft tissue gas - Dislocations in neuropathic arthropathy CT Scan Technetium bone scans - osteomyeletis MRI - osteomyelitis

16. Prevention Management

17. Regular inspection of the foot, appropriate nail care, warm (32 o C) soaks, moisturizing creams, early detection of new lesions Optimally fitted footwear – well cushioned sneakers, custom molded shoes Pressure reduction – cushioned insoles, custom orthoses Patient education — need for daily inspection and necessity for early intervention, avoidance of barefoot walking Physician education — significance of foot lesions, importance of regular foot examination, and current concepts of diabetic foot management

18. Diabetic foot care Debridement – of callus and necrotic tissue using sharp debridement till bleeding tissue, lavage and dressings Wound management – maintenance of a moist wound with regular cleaning and dressing Infections treated with broad spectrum antibiotics based on culture results. Clindamycin / flouroquinolone / metronidazole suitable empiric therapy

19. Wound management After debridement, apply a moist sodium chloride dressing or isotonic sodium chloride gel ( eg , Normlgel , IntraSite gel) or a hydroactive paste ( eg , Duoderm ). A polyvinyl film dressing ( eg , OpSite , Tegaderm ) that is semipermeable to oxygen and moisture and impermeable to bacteria is a good choice for wounds that are neither very dry nor highly exudative .

20. Wound coverage recommendations for some other wound conditions are as follows : Dry wounds : Hydrocolloid dressings, such as DuoDERM or IntraSite Hydrocolloid, are impermeable to oxygen, moisture, and bacteria; maintain a moist environment; and support autolytic debridement. They are a good choice for relatively d ry wounds.

21. Exudative wounds : Absorptive dressings, such as calcium alginates ( eg , Kaltostat , Curasorb ), are highly absorptive and are appropriate for exudative wounds. Alginates are available in a rope form, which is useful for packing deep wounds.

22. Very exudative wounds : Impregnated gauze dressings ( eg , Mesalt ) or hydrofiber dressings ( eg , Aquacel , Aquacel -Ag) are useful for extremely exudative wounds. In these cases, twice-daily dressing changes may be needed

23. I nfected wounds : For infected superficial wounds, use Silvadene (silver sulfadiazine) if the patient is not allergic to sulfa drugs; if a sulfa allergy exists, either bacitracin -zinc or Neosporin ointment is a good alternative. Where heavy bacterial contamination of deeper wounds exists, irrigation using one-fourth strength Dakin solution and 0.25% acetic acid may be useful for a brief period of time; a hydrofiber -silver dressing ( Aquacel -Ag) can help control wounds that are both exudative and potentially colonized

24. Wounds covered by dry eschar : In this case, simply protecting the wound until the eschar dries and separates may be the best management. Occasionally, painting the eschar with povidone iodine ( Betadine ) is beneficial to maintain sterility while eschar separation occurs; an uninfected dry heel ulcer in a well- perfused foot is perhaps best managed in this fashion. Areas that are difficult to bandage : Bandaging a challenging anatomical area, such as around a heel ulcer, requires a highly conformable dressing, such as an extra thin hydrocolloid; securing a dressing in a highly moist challenging site, such as around a sacrococcygeal ulcer, requires a conformable and highly adherent dressing, such as a wafer hydrocolloid.

25. Sharp debridement Local procedures to remove areas of chronically elevated pressure (deformities) causing non healing ulcers Sequestrectomies Correct structural deformities — hammer toes , bunions , Charcot Amputation Surgery INDICATION Uncontrollable infection or sepsis Non ambulatory patient

26. Summary

27. References Apley’s System of Orthopedics and Fractures 9 th Edition Davidson’s Principles and Practices of Medicine 22 nd Edition Bailey’s and Love Short Practices of Surgery, 26 th Edition Internet.