Diabetic Foot

Front 1

What is the diabetic foot triad?

Back 1

Vasculopathy

- peripheral vascular disease

- microangiopathy --> nail changes, gangrene of digits

Immunopathy

- monomicrobial vs polymicrobial

- predominantly gram +ve cocci, followed by gram -ve and anaerobes

- present as abscess, OM, septic arthritis, cellulitis

Neuropathy

- glove and stocking sensory loss (sensation)

- clawing of toes (motor)

- dryness of skin (autonomic)

Front 2

What are the different presentations of a diabetic foot?

Back 2

1. Ulcers (neuropathic, vascular, decubitus)

2. Cellulitis OR necrotizing fasciitis (TRO)

3. Gangrene (wet vs dry)

4. Infection (osteomyelitis, septic arthritis, abscess, necrotizing fasciitis, gas gangrene)

5. Charcot foot

Front 3

What are the common areas for the different types of ulcers?

Back 3

1. vascular/ischemic

- dorsum of foot

- 1st web spae

- heel

- toes

- anterior shin

- lateral aspect of leg

- bony areas

2. Neuropathic ulcer (tripod stance)

- sole of foot

- pulp of toe

3. Decubitus

- heel

- lateral aspect of base of 5th metatarsal

4. Venous

- Medial aspect of leg (may be behind malleolus)

- Gaiter's area

Front 4

What is the definition of critical limb ischemia?

Back 4

1. rest pain that is relieved by dependency

2. gangrene

3. ischemic ulcer

*** pallor <20 degree of lifting foot up

*** ABPI < 0.5 is critical limb ischemia

*** other symptoms of limb ischemia: claudication, 6 Ps (pallor, parasthesia, pain, paralysis, pulselessness, perishingly cold)

Front 5

What are the examination findings of charcot's joint?

Back 5

- enlargement of joint

- hypermobility of joint

- warm and swollen initially, followed by crepitus in later stages

- may have collapse of midfoot and rocker bottom deformity as a result

- commonly affects mid tarsal joints, followed by metatarsophalangeal joint and finally ankle joint

Front 6

What is the pathophysiology of hammer toes, mallet toes & claw toes?

Back 6

1. imbalance between intrinsic and extrinsic muscle strength

mallet toes: flexion deformity of DIPJ, with no PIPJ or MTPJ involvment

claw toes: flexion deformity at DIPJ and PIPJ

hammer toes: flexion deformity of PIPJ

Front 7

How to assess for vasculopathy?

Back 7

1) skin changes:

- loss of hair

- pale/dusky discoloration

- shiny

- trophic nail changes

- hyperpigmentation

2) Look for ischemic ulcers

3) Assess for temperature of skin (perishingly cold)

4) Assess for capillary refill time

5) Assess for all peripheral pulses

6) Buerger's test (conduct if 1 or more pulses are not palpable)

- indicates PVD

- also assess for severity of PVD based on the vascular angle

Front 8

How to assess for neuropathy?

Back 8

1) Pin prick testing in glove and stocking distribution

- look for hyperaesthesia, hypoaesthesia, anaesthesia

2) Propioception and vibration sense

3) Tendon reflex (ankle jerk)

4) protective sensation via 10 points semmes weinstein monofilament testing

- should be more than 7 in normal patients

Front 9

What are the signs of autonomic neuropathy on skin?

Back 9

- dry skin

- scaling

- fissuring

- callosity (tips of toes/soles)

Front 10

What is the definition of charcot's joint?

x-ray changes of charcot's joint?

Back 10

Progressive degeneration of a weight bearing joint, resulting in deformity

pathophysiology is either

a) increased osteoclasts to area due to increased blood supply and hence collapse of foot bony structure

b) repetitive microtrauma leading to inflammatory resorption, hence collapse of foot bony structure

** a/w with hypertrophic changes on x-ray usually:

- density increase

- debris

- distended joint

- dislocation

- disorganisation

- destruction of joint

Front 11

Describe and diagnose

Back 11

Charcot foot:

- destruction of tarsometatarsal joints

- sclerotic margins

- general disorganization of tarsal bones

- joint surface uneven

Front 12

Indications of amputation?

Back 12

- dead limb

- dangerous limb

- damn nuisance

Front 13

Types of amputation?

Back 13

ray (tarso-metatarsal of 1 ray) > Forefoot (trans-metatarsal)> lisfranc (tarso-metatarsal) > chopart's (mid tarsal)> syme's (through ankle) > BKA > AKA

Front 14

King's classification of DM foot

Back 14

• stage 1 normal
  
• stage 2 have risk factors
  
• stage 3 have ulcers --> superficial (conservative tx), deep (surgical debridement)
  
• stage 4 has cellulitis (may be a/w OM, abscess) --> KIV partial amputation
  
• stage 5 has gangrene (forefoot vs midfoot vs hind foot vs whole foot)
  
• stage 6 needs amputation
  

Front 15

general management of diabetic foot?

Back 15

1) control DM

- hypocount charting TDS + 10pm

- start insulin sliding scale

2) prevent dehydration

- IO charting

- IV at least 1.5 L a day

3) cover with topical and oral/IV antibiotics

- trace blood culture

- trace wound culture

- trace inflammatory markers: ESR, CRP, FBC

- change from broad spectrum to specific antibiotics after culture results are out

4) Daily wound dressing

5) Elevate the limb if swollen

Front 16

Specific management plan for diabetic foot

Back 16

1. Ulcers:

- radical debridement if deep and dirty

- Vascular consult (KIV angioplasty)

- KIV amputation, depending on presence of contamination, OM, cellulitis, abscess, vascularity etc

- special footwear, offloading

2. Gangrene

- If dry: wait for the segment to auto-amputate, and clean the area regularly

- If wet: amputation

- Vascular consult

3. Abscess:

- I&D in OT

Front 17

MDM team for DM foot

Back 17

surgeons: ortho, vascular

medical: endocrinologists, ID specialists, KIV renal

allied health: podiatrist, dietician, PT, OT, MSW

nurses: DM nurse, wound care nurse

KIV amputation support group

Front 18

Specific treatment for charcot's foot

Back 18

o Conservative

 Contact casting

 Charcot restraint orthotic walker (CROW)

 Refer podiatrist for shoe modifications

 Bisphosphonate therapy

o Surgical

 Exostectomy

 Correct the deformities using plates and screws

 Arthrodesis

Front 19

What is this

Back 19

charcot restraint orthotic walker (CROW)