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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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slide2

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
World Diabetes Day 2005

Diabetes and Foot Care

Put Feet First

Prevent Amputations

campaign objectives
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.
foot facts 1
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?)
foot facts 2
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.

slide8

Egypt Representative

Mansoura University

Prof.Mamdouh El Nahas.

Dr.Hanan Gawish

Dr. Manal Tarshoby

Dr.Omnia Stat

levels of foot management
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
slide10

Value of Podiatric Care

  • KINGS COLLEGE HOSPITAL.
  • 1984 establishment of
  • DIABETIC FOOT CLINIC.
  • Amputation decreased 50% in
  • 3 years.
diabetic foot disease
Diabetic Foot Disease
  • Ischaemia
  • Neuropathy
  • Infection
  • Structural deformity
  • Ulcer
  • Amputation
slide13

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

slide14

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

regular inspection and examination of the foot
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
history
History
  • Previous ulcer , amputation
  • Previous foot education
  • Bare-foot walking
  • Poor access to healthcare
  • Smokimg , alcohol
  • Nephropathy,Retinopathy
  • Hypertension
  • Ischemic heart disease
foot examination
Foot examination
  • Nails

Thick

too long

ingrown

fungal infection

wrongly cut nails

foot examination18
Foot Examination
  • Foot deformity:
foot examination19
Foot Examination
  • Foot deformity:

Toe deformity

  • Hammer toe
  • Claw toe
toe deformity hammer toe
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
foot examination21
Foot Examination
  • Foot deformity:

Toe deformity

Forefoot deformity

  • Hallux valgus
  • Hallux rigidus
slide23

Hallux Rigidus

Osteoarthritic Degeneration 1st MTP Joint

Limitation of Dorsiflexion

Overloading 2nd MTP Joint / 1st IPJoint

foot examination24
Foot Examination
  • Foot deformity:

Toe deformity

Forefoot deformity

Wholefoot Deformities

  • Pes Cavus - High arched foot
  • Pes Planus - Flat foot
  • Charcot foot
diagnosis of acute charcot
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.
foot examination27
Foot Examination
  • Foot deformity:

Toe deformity

Forefoot deformity

Whole foot Deformities

Prominent metatarsal heads

foot examination28
Foot Examination
  • Skin condition:

Callus Bunions

Redness Warmth

Fissure Dryness

Swelling Maceration

Fungal infection

callus
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.
foot examination31
Foot Examination
  • Vascular assessment:

History

Intermitent claudication

Rest pain

Colour of the skin

Temperature gradient

foot examination32
Foot Examination
  • Vascular assessment:

Pedal pulse

Dorsalis pedis

Posterior tibial

foot examination33
Foot Examination
  • Vascular assessment:

Pedal pulse

Dorsalis pedis

Posterior tibial

Ankle Brachial Pressure Index

foot examination34

Tempreature

  • Vibration Sense
  • Touch and Pressure
  • Light Touch
  • Proprioception (Romberg’s Sign)
  • Superficial Pain
  • Reflexes
Foot Examination
  • Neurological assessment:
neurologic assessment
Neurologic assessment
  • Temperature
  • Vibration Sense
  • Pressure Sense
  • Light Touch
  • Proprioception
  • Reflexes
neurologic assessment37
Neurologic assessment
  • Temperature
  • Vibration Sense
  • Pressure Sense
  • Light Touch
  • Proprioception (Romberg’s Sign)
  • Superficial Pain
  • Reflexes
temperature testing
TEMPERATURE TESTING
  • Two test tubes, hot/cold.
  • Therm-tip
  • Subjective, crude tests
neurologic assessment39
Neurologic assessment
  • Temperature
  • Vibration Sense
  • Pressure Sense
  • Light Touch
  • Proprioception
  • Superficial Pain
  • Reflexes
neurologic assessment42
Neurologic assessment
  • Temperature
  • Vibration Sense
  • Pressure Sense
  • Light Touch
  • Proprioception
  • Superficial Pain
  • Reflexes
slide43

MONOFILAMENTS

  • 10 gm
  • Sites tested
  • Technique
  • Significance
neurologic assessment45
Neurologic assessment
  • Temeprature
  • Vibration Sense
  • PressureSense
  • Light Touch
  • Proprioception
  • Superficial Pain
  • Reflexes
neurologic assessment47
Neurologic assessment
  • Temperature
  • Vibration Sense
  • Pressure Sense
  • Light Touch
  • Proprioception
  • Superficial Pain
  • Reflexes
slide48

PROPRIOCEPTION TEST

  • Tested by dorsiflexing and plantarflexing the hallux. Can the patient determine the position of the hallux?
neurologic assessment49
Neurologic assessment
  • Temperature
  • Vibration Sense
  • Pressure Sense
  • Light Touch
  • Proprioception
  • Superficial Pain
  • Reflexes
neurologic assessment51
Neurologic assessment
  • Temperature
  • Vibration Sense
  • Pressure Sense
  • Light Touch
  • Proprioception
  • Superficial Pain
  • Reflexes
slide53

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

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

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

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

foot care team
Foot care team
  • ??Podiatrists
  • Orthotists.
  • Diabetologists.
  • Vascular Surgeon.
  • Educators.
  • Microbiologist.
slide61
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)

slide62
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.
dressing

Dressing

No evidence from large trials

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

debridement

Debridement

Sharp

Larval

Enzymatic (Lytic)

Indication & Contraindication??

offlaoding
Offlaoding
  • What is meant by offloading
  • Different offloading modalities
key message
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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