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Prof.Mamdouh El Nahas. Hanan Gawish Dr Manal Tarshoby. Dr.Omnia State. Diabetic Foot An Overview. Foot team Prof.Mamdouh El Nahas Prof.Hanan Gawish Dr. Manal Tarshoby Dr.Omnia State. World Diabetes Day 2005. Diabetes and Foot Care. Put Feet First Prevent Amputations.

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Prof.Mamdouh El Nahas.

Hanan Gawish

Dr Manal Tarshoby.

Dr.Omnia State.

Diabetic Foot

An Overview

Foot team

  • Prof.Mamdouh El Nahas

  • Prof.Hanan Gawish

  • Dr. Manal Tarshoby

  • Dr.Omnia State


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World Diabetes Day 2005

Diabetes and Foot Care

Put Feet First

Prevent Amputations



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Campaign Objectives

  • Inform people of the extent of diabetic foot problems worldwide.

  • Persuade people that action is both possible and affordable.

  • Warn people of the consequences of not taking action.


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FOOT FACTS(1)

  • Every 30 seconds a leg is lost to diabetes somewhere in the world.

  • Up to 70% of all leg amputations happen to people with diabetes.

  • DF problems are the commonest cause of hospital admission. (by us?)


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FOOT FACTS(2)

  • Most amputations begin with a foot ulcer.

  • One in every six people with diabetes will have a foot ulcer during their lifetime.

  • Good News

    Up to 85% of amputations can be avoided.


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Egypt Representative

Mansoura University

Prof.Mamdouh El Nahas.

Dr.Hanan Gawish

Dr. Manal Tarshoby

Dr.Omnia Stat


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Levels of foot management

  • Level 1 General practitioner, diabetic nurse and podiatrist

  • Level 2 Diabetologist, surgeon (general and/or vascular and/or orthopedic), diabetic nurse and podiatrist

  • Level 3 Specialized foot center


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Value of Podiatric Care

  • KINGS COLLEGE HOSPITAL.

  • 1984 establishment of

  • DIABETIC FOOT CLINIC.

  • Amputation decreased 50% in

  • 3 years.



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Diabetic Foot Disease

  • Ischaemia

  • Neuropathy

  • Infection

  • Structural deformity

  • Ulcer

  • Amputation


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Regular inspection and examination of the foot.Identification of the foot at risk.Education of patient, family and healthcare providers.Appropriate footwear.Treatment of non ulcerative pathology

Five cornerstones of the management

of the diabetic foot


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Regular inspection and examination of the foot.Identification of the foot at risk.Education of patient, family and healthcare providers.Appropriate footwear.Treatment of non ulcerative pathology

Five cornerstones of the management

of the diabetic foot


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Regular inspection and examination of the foot

  • All diabetic patients should be examined at first presentation then at least once a year

  • Patients with risk factors should be examined every 1-6 months

  • Absent symptoms does not mean that the feet are healthy

  • Examine the patient on lying down and standing up

  • Shoe and socks should be inspected


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History

  • Previous ulcer , amputation

  • Previous foot education

  • Bare-foot walking

  • Poor access to healthcare

  • Smokimg , alcohol

  • Nephropathy,Retinopathy

  • Hypertension

  • Ischemic heart disease


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Foot examination

  • Nails

    Thick

    too long

    ingrown

    fungal infection

    wrongly cut nails


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Foot Examination

  • Foot deformity:


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Foot Examination

  • Foot deformity:

    Toe deformity

  • Hammer toe

  • Claw toe


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Toe Deformity:– Hammer Toe

  • Increased pressure on 2ndmetatarsal head

  • Increased pressure on prox. IPJ

  • Increased pressure on distal IPJ

  • Increased pressure on apex

  • Increased pressure on nail fold


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Foot Examination

  • Foot deformity:

    Toe deformity

    Forefoot deformity

  • Hallux valgus

  • Hallux rigidus



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Hallux Rigidus

Osteoarthritic Degeneration 1st MTP Joint

Limitation of Dorsiflexion

Overloading 2nd MTP Joint / 1st IPJoint


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Foot Examination

  • Foot deformity:

    Toe deformity

    Forefoot deformity

    Wholefoot Deformities

  • Pes Cavus - High arched foot

  • Pes Planus - Flat foot

  • Charcot foot


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Diagnosis of Acute Charcot

  • Painless

  • Redness, swelling, and more than 2°C skin temperature difference when compared with the contralateral foot.

  • Dorsalis pedis pulses are often bounding.

  • The patient is afebrile unless a systemic infection is present.


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Foot Examination

  • Foot deformity:

    Toe deformity

    Forefoot deformity

    Whole foot Deformities

    Prominent metatarsal heads


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Foot Examination

  • Skin condition:

    Callus Bunions

    Redness Warmth

    Fissure Dryness

    Swelling Maceration

    Fungal infection


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Callus

  • Presence of callus is a significant marker for the development of foot ulceration

  • The hyperkeratosis is a result of hypertrophy under the influence of intermittent compression .

  • the callus is either a reaction to abnormal pressure or an abnormality of the area to handle normal pressure.



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Foot Examination

  • Vascular assessment:

    History

    Intermitent claudication

    Rest pain

    Colour of the skin

    Temperature gradient


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Foot Examination

  • Vascular assessment:

    Pedal pulse

    Dorsalis pedis

    Posterior tibial


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Foot Examination

  • Vascular assessment:

    Pedal pulse

    Dorsalis pedis

    Posterior tibial

    Ankle Brachial Pressure Index


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  • Tempreature

  • Vibration Sense

  • Touch and Pressure

  • Light Touch

  • Proprioception (Romberg’s Sign)

  • Superficial Pain

  • Reflexes

Foot Examination

  • Neurological assessment:


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Neurologic assessment

  • Temperature

  • Vibration Sense

  • Pressure Sense

  • Light Touch

  • Proprioception

  • Reflexes



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Neurologic assessment

  • Temperature

  • Vibration Sense

  • Pressure Sense

  • Light Touch

  • Proprioception (Romberg’s Sign)

  • Superficial Pain

  • Reflexes


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TEMPERATURE TESTING

  • Two test tubes, hot/cold.

  • Therm-tip

  • Subjective, crude tests


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Neurologic assessment

  • Temperature

  • Vibration Sense

  • Pressure Sense

  • Light Touch

  • Proprioception

  • Superficial Pain

  • Reflexes




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Neurologic assessment

  • Temperature

  • Vibration Sense

  • Pressure Sense

  • Light Touch

  • Proprioception

  • Superficial Pain

  • Reflexes


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MONOFILAMENTS

  • 10 gm

  • Sites tested

  • Technique

  • Significance


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Neurologic assessment

  • Temeprature

  • Vibration Sense

  • PressureSense

  • Light Touch

  • Proprioception

  • Superficial Pain

  • Reflexes



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Neurologic assessment

  • Temperature

  • Vibration Sense

  • Pressure Sense

  • Light Touch

  • Proprioception

  • Superficial Pain

  • Reflexes


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PROPRIOCEPTION TEST

  • Tested by dorsiflexing and plantarflexing the hallux. Can the patient determine the position of the hallux?


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Neurologic assessment

  • Temperature

  • Vibration Sense

  • Pressure Sense

  • Light Touch

  • Proprioception

  • Superficial Pain

  • Reflexes



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Neurologic assessment

  • Temperature

  • Vibration Sense

  • Pressure Sense

  • Light Touch

  • Proprioception

  • Superficial Pain

  • Reflexes



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Regular inspection and examination of the foot.Identification of the foot at risk.Education of patient, family and healthcare providers.Appropriate footwear.Treatment of non ulcerative pathology

Five cornerstones of the management

of the diabetic foot




Slide56 l.jpg

Regular inspection and examination of the foot.Identification of the foot at risk.Education of patient, family and healthcare providers.Appropriate footwear.Treatment of non ulcerative pathology

Five cornerstones of the management

of the diabetic foot


Slide57 l.jpg

Regular inspection and examination of the foot.Identification of the foot at risk.Education of patient, family and healthcare providers.Appropriate footwear.Treatment of non ulcerative pathology

Five cornerstones of the management

of the diabetic foot


Slide58 l.jpg

Regular inspection and examination of the foot.Identification of the foot at risk.Education of patient, family and healthcare providers.Appropriate footwear.Treatment of non ulcerative pathology

Five cornerstones of the management

of the diabetic foot



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Foot care team

  • ??Podiatrists

  • Orthotists.

  • Diabetologists.

  • Vascular Surgeon.

  • Educators.

  • Microbiologist.


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Ulcer assessment

  • Establish the ulcer's etiology

  • Measure its size

  • Establish its depth and involvement of deep structures

  • Examine it for purulent exudates, necrosis, sinus tracts, and odor

  • Assess the surrounding tissue for signs of edema, cellulitis, abscess, and fluctuation

  • Exclude systemic infection

  • Perform a vascular evaluation.

  • The ability to gently probe through the ulcer to bone has been shown to be highly predictive of osteomyelitis.

    (should be recorded at base line and every subsequent visits ± digital photo)


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  • A multidisciplinary approachproviding debridement, meticulous wound care, adequate vascular supply, metabolic control, antimicrobial treatment and relief of pressure (offloading) is essential in the treatment of foot ulcer.


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Dressing

No evidence from large trials

Do not put anything on the ulcer that you wouldn’t put in your eye!!


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Debridement

Sharp

Larval

Enzymatic (Lytic)

Indication & Contraindication??



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Offlaoding

  • What is meant by offloading

  • Different offloading modalities


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Key Message

  • Of all late complications of diabetes, foot problems are the most easily detectable and easily preventable.

  • Relatively simple interventions can reduce amputations by 50 - 80%. (Bakker et al 1994).

  • Strategies aimed at preventing foot ulcers are cost effective and cost saving.

  • Only champions willing to act are needed.




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