Diabetic Foot

Pathophysiology
Vascular disease?
Neuropathy
Sensory
Motor
autonomic
 Vascular Disease
30 times more prevalent in diabetics
Diabetics get arthrosclerosis obliterans or
lead pipe arteries
Calcification of the media
Often increased blood flow with lack of elastic
properties of the arterioles
Not considered to be a primary cause of foot
ulcers
Peripheral Artery
Disease
10%-20% in type 2 diabetes at diagnosis
30% in diabetics age 50 years
40%-60% in diabetics with foot ulcer

Diabet Med. 2005;22:1310

Diabetes Care. 2003;26:3333
 Neuropathy
Changes in the vasonervorum with
resulting ischemia ? cause
Increased sorbitol in feeding vessels block
flow and causes nerve ischemia
Intraneural acculmulation of advanced
products of glycosylation
Abnormalities of all three neurologic
systems contribute to ulceration
 Sensory Neuropathy
Loss of protective sensation
Starts distally and migrates proximally
in stocking distribution
Large fibre loss light touch and
proprioception
Small fibre loss pain and temperature
Usually a combination of the two
 Sensory Neuropathy
Two mechanisms of Ulceration
Unacceptable stress few times
rock in shoe, glass, burn
Acceptable or moderate stress
repeatedly
Improper shoe ware
deformity
 Motor Neuropathy
Mostly affects forefoot ulceration
Intrinsic muscle wasting claw toes
Equinous contracture
 Autonomic Neuropathy
Regulates sweating and perfusion
Loss of autonomic control inhibits
thermoregulatory function and sweating
Result is dry, scaly and stiff skin that is
prone to cracking and allows a portal of
entry for bacteria
Autonomic Neuropathy
 Gangguan Neuropati
Paralisis
Perubahan faal muskuloskeletal kaki
Perubahan anatomi
Titik tekan di telapak kaki lain
Mati rasa
Cedera tak disadari
Tekanan pada luka tak dihindari
Gangguan faal saraf otonom
Perfusi kulit kurang
Pintas arteri vena kulit terbuka
PATHOGENESIS OF DIABETIC FOOT ULCER AND AMPUTATION
Sensory Joint Motor Autonomic PAD
Neuropathy Mobility Neuropathy Neuropathy

Protective Muscle atrophy and Sweating Ischemia

sensation 2 foot deformities 2 dry skin

Foot pressure Foot pressure Fissure Healing

Minor trauma esp. over
recognition bony prominences

Callus Pre-ulcer ULCER Infection AMPUTATION

Minor Trauma: Interdigital Maceration

Mechanical (Moisture, Fungus)
Chemical
Thermal

2006. American College of Physicians. All Rights Reserved.

Pathway to diabetic foot
Nerve damage problems
Poor blood supply

Injury

Ulcer
Infection
Amputation
 Causal Pathways for
Neuropathy
Foot Ulcers
% Causal Pathways

Neuropathy: 78%
Minor trauma: 79%
Deformity
Deformity: 63%
Behavioral ?
Minor Trauma
- Mechanical (shoes)
- Thermal
Poor self-foot care

- Chemical

ULCER Diabetes Care. 1999; 22:157

 PENYEBAB
Angiopati
Perdarahan jaringan marginal
Neuropati
Paralisis otot kaki
Rasa mati
Gangguan saraf otonom
Trauma
Motor Neuropathy and
Foot Deformities
Hammer toes
Claw toes
Prominent metatarsal heads
Hallux valgus
Collapsed plantar arch
Hammer Toes

Claw Toes

2002 American Diabetes Association

From The Uncomplicated Guide to Diabetes Complications
Reprinted with permission from The American Diabetes Association
 Hallu
x
Valgu
s

2002 American Diabetes Association

From The Uncomplicated Guide to Diabetes Complications
Reprinted with permission from The American Diabetes Association
Boulton, et al. Guidelines for Diagnosis of Outpatient Management of Diabetic
Peripheral Neuropathy. Diabetic Medicine 1998, 15:508-512
Pre-ulcer Cutaneous
Pathology
Persistent erythema after shoe
removal
Callus
Callus with subcutaneous
hemorrhage
Interdigital maceration, fungal
infection
Nail pathology
 Pre-
ulcer

AJM Boulton, H Connor, PR Cavanagh, The Foot in Diabetes, 2002

 Sukar sembuh karena:
Trauma terus menerus
Tekanan abnormal
Lingkungan diabetes subur untuk
berkembangnya kuman patogen
Perfusi jaringan kulit kurang baik
Kurang mendapat nutrien
Vibration Testing
Biothesiometer
Best predictor of foot ulcer risk
128-Hz tuning fork at halluces
Equivalent to 10-g monofilament
Newly recommended by ADA

Diabetes Care. 2006;29(Suppl 1):S25

Diabetes Res Clin Pract. 2005;70:8
 Diagnosis Angiopati
Diabetes
Gambaran klinis
Derajat kelainan kaki
Tipe angiopati
Makroangiopati
Mikroangiopati
Sifat Obstruksi
Akut
Kronik
Status pembuluh darah
Pulsasi denyut nadi
Doppler
BASIC FOOT CARE CONCEPTS

Daily foot inspection

May require mirror, magnification, or
caregiver
Educate patient to recognize/report
ASAP:
Persistent erythema
Enlarging callus
Pre-ulcer (callus with hemorrhage)

2006. American College of Physicians. All Rights Reserved.

 BASIC FOOT CARE CONCEPTS

Commitment to self-care:
Wash/dry daily
Avoid hot water; dry thoroughly between toes
Lubricate daily (not between toes)
Debride callus/corn to reduce plantar
pressure 25%
Avoid sharp instruments, corn plasters
No self-cutting of nails if:
Neuropathy and poor vision

2006. American College of Physicians. All Rights Reserved.

BASIC FOOT CARE CONCEPTS

Protective behaviors:
Avoid temperature extremes
No walking barefoot/stocking-footed
Appropriate exercise if sensory
neuropathy
Bicycle/swim > walking/treadmill
Inspect shoes for foreign objects
Optimal footwear at all times

2006. American College of Physicians. All Rights Reserved.

Basic Footwear
Education Favor:
Avoid: Broad-round toes
Pointed Athletic shoes, walking
toes shoes
High
Leather, canvas
heels
Plastic White/light colors
Black between longest
color toe and end of shoe
Too small

Diabetes Self-Management. 2005;22:33

2006. American College of Physicians. All Rights Reserved.
 Patient Evaluation
Medical
Vascular
Orthopedic
Identification of Foot at Risk
 Patient Evaluation
Medical
Optimized glucose control
Decreases by 50% chance of foot
problems
 Patient Evaluation
Vascular
Assessment of peripheral pulses of
paramount importance
 Patient Evaluation
Orthopedic
Ulceration
Deformity and prominences
Contractures
 Patient Evaluation
X-ray
Lead pipe arteries
Bony destruction (Charcot or
osteomyelitis)
Gas, F.B.s
Patient Evaluation
 Patient Evaluation
CT can be helpful in visualizing
bony anatomy for abscess, extent
of disease
MRI has a role instead of nuclear
medicine scans in uncertain cases
of osteomyelitis
 Derajat Kelainan Kaki
Diabetik (WAGNER)
Derajat Sifat
Luka Abses Selulitis Osteo Gang
mielitis gren
0 - - - - -

I Superfisial - - - -

II sampai - - - -
tendo/
tulang
III Dalam ++ +/- +/- -

IV Dalam +/- +/- +/- Jari

V Ganggren Seluruh
kaki
Classification
Type 2 or 3
Classification
Type 4
 Treatment
Patient education
Ambulation
Shoe ware
Skin and nail care
Avoiding injury
Hot water
 Treatment
Wagner 0-2
Total contact cast
Distributes pressure and allows
patients to continue ambulation
Principles of application
Changes, Padding, removal
Antibiotics if infected
Treatment
 Treatment
Wagner 0-2
Surgical if deformity present that will
reulcerate
Correct deformity
exostectomy
 Treatment
Wagner 3
Excision of infected bone
Grafting (skin or bone) not generally
effective
 Treatment
Wagner 4-5
Amputation
Level ?
 Treatment
After ulcer healed
Orthopedic shoes with
accommodative (custom made insert)
Education to prevent recurrence
Indications for Amputation
Uncontrollable infection or sepsis
Inability to obtain a plantar grade,
dry foot that can tolerate weight
bearing
Non-ambulatory patient
2006. American College of Physicians. All Rights Reserved.