29/04/2018
Diabetic foot:
Up to 15% of patients with diabetes will develop a foot ulcer at some point in their lives. In addition, nonhealing foot ulcers precede almost 85% of lower-limb amputations.
Diabetic neuropathy is the most common underlying etiology. Sensory neuropathy causes loss of protective sensation, resulting in repetitive stress that eventually leads to ulcer formation; autonomic neuropathy results in reduced sweating, thereby causing dry skin and fissure formation, and predisposing the skin to infection.
Ischemia secondary to peripheral vascular disease may also result in ulceration - although this is more often a contributory factor than the sole cause.
Foot deformities such as bunions, calluses and hammertoes (which are common in diabetic patients) may lead to focal areas of high pressure, thereby contributing to ulcer formation.
In most cases, the causative etiology or etiologies can be determined clinically. The investigative workup should be tailored to the clinical findings, and include neurological, circulatory and radiological assessment as necessary.
The neurological assessment should include determination of vibration thresholds by means of a 128-Hz tuning fork, and detection of protective sensation via a 10 gauge monofilament
An x-ray should be ordered in all ulcers which are deep, infected, or non-healing, to exclude osteomyelitis. CT and MRI scans may be considered if a plantar abscess is suspected.
The principles of management include treatment of the ulcer, treatment of the underlying etiology, and prevention of further ulcer formation.
Wound debridement is the first step in treating the ulcer. This involves removal of all necrotic tissue, peri-wound callus, and foreign bodies, until viable tissue remains. This will decrease the risk of infection and reduce peri-wound pressure (which can otherwise impair healing and normal wound contraction).
Following debridement, a moist dressing should be applied in order to promote wound healing. Note that dressings should not be changed overly frequently, as this will impede wound healing.
As neuropathic ulcers frequently occur at pressure points, offloading (i.e. effective redistribution and relief of pressure) is a critical element of the management. Techniques in this regard include the use of casts or boots, and felted foam dressings.
In certain patients, skin grafting may be considered once the ulcer has healed, and healthy granulation tissue is present. Note that the effectiveness of skin replacement therapy in the management of diabetic ulcers is still unestablished.
Antibiotics should be prescribed if the ulcer appears to be infected. If underlying osteomyelitis is present, aggressive resection of infected bone and joints followed by 4 to 6 weeks of culture-directed antibiotic therapy may be required.
Treatment of contributory conditions includes proper glycemic control and detection and treatment of ischemia, if present. Most ulcers with an ischemic component will not heal completely until the ischemia has resolved.
In certain patients, amputation may have to be performed as a last resort, especially if the combination of deep infection and ischemia is present.
Once the ulcer has healed, it is important to maintain skin integrity in order to prevent recurrence. This is done by recognition of risk factors, and educating the patient about proper foot care.
Important elements with regard to foot care include daily foot inspection, gentle soap and water cleansing, application of skin moisturizer and proper trimming of nails.
It is also critical to educate the patient about proper footwear. Their shoes should protect the feet, fit well and be deep and wide enough to prevent rubbing....!!
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