Diabetic foot

Introduction

Million people all over the world have the disease. The problem affects about 60 to 70 percent of people with diabetes.??Foot problems are a big risk.

Diabetes mellitus results in serious foot problems that may cause loss of limb or life. 


Causes
These conditions include diabetic neuropathy (loss of normal nerve function) and peripheral vascular disease (loss of normal circulation), associated with anatomical conditions of the foot ( bone prominences, misalignment), pathological  events such as ingrown toenail, injuries affecting the foot and poorly fitting shoes which may cause:

  • Diabetic foot ulcers: wounds that may not heal or may become infected.
  • Infections: skin infections (cellulitis), bone infections (osteomyelitis), and pus collections (abscesses).
  • Gangrene: dead tissue resulting from complete loss of circulation.
  • Charcot joints: fractures and dislocations that may result in severe deformities (discussed in a separate article).
  • Amputation: partial foot, whole foot, or below-knee amputation.


Symptoms diagnosis
Nerve function may be abnormal, so the patient may not feel pain.  This frequently causes a delay in the diagnosis, and the patient may present late in the course, with a limb- or life-threatening infection. 

The patient may develop a blister, abrasion, or wound, but may not feel any pain.  Decreased circulation may cause discoloration of skin, temperature changes, or pain.  Depending on the specific problem that develops, patients may notice swelling, discoloration (red, blue, grey, or white), red streaks, changes in skin temperature (increased warmth or coolness), injury with no or minimal pain, a wound with or without drainage, staining on socks, tingling pain, or deformity.  Patients with infection may have fever, chills, shakes, redness, drainage, loss of blood sugar control, or shock (unstable blood pressure, confusion, and delirium).

Absence of protective sensation may be confirmed by the failure to sense pressure from a nylon Semmes-Weinstein monofilament (number 5.07, equivalent to 10 g).

Radiographs may show gas in the soft tissues, soft tissue swelling or defect, or changes consistent with bone infection, fracture, or dislocation (Charcot 'foot). 

Ulcers are graded for size, depth (exposed tissues), and vascularity. 

Additional imaging studies may be helpful, including bone scan, gallium scan, indium scan, magnetic resonance imaging scan, or computed tomography scan.  Cultures of tissue from the base of an ulcer may be more reliable than swab cultures from the ulcer.  Vascular studies (Doppler toe pressures and ankle-brachial index) may help determine adequacy of circulation for wound healing.


Non-Surgical traitement

Wounds may be debrided and treated with dressings and immobilization devices such as cast boots or total contact casts. 
Infections are treated with debridement and antibiotics (intravenous or oral).
Non-operative treatment for Charcot joints may include protective immobilization with or without weightbearing.
Gangrene of the toes may be treated with observation (if infection is under control) until “auto-amputation”occurs.

 

Surgical Treatement

Severe infections such as abscess may be treated with urgent radical operative debridement or amputation.
Surgical treatment for Charcot foot may include operative stabilization (fusion) and correction of deformity.
Vascular disease may be treated by vascular surgeons with arterial bypass procedures.
Gangrene may be treated with partial foot amputation or below-knee amputation.


Prevention
Is mandatory

Patients with diabetes must exercise extreme caution. Properly fitting shoes can help protect feet and avoid injury. Any injury, no matter how minor, deserves careful attention. You also must always exercise great caution in trimming toenails. Avoid trimming corns and calluses.

Do:

  • Inspect feet daily for pressure spots, cuts and bruises
  • Ask your physician to check your feet
  • Inspect shoes for folds and nails
  • Bathe feet daily
  • Tell shoe salespeople you are diabetic
  • Change shoes at least once a day
  • Make sure toenails are trimmed ?

Don't:

  • Go barefoot
  • Use corn removers
  • Cut calluses or corns
  • Ignore redness or ulceration of the foot