the diabetic foot - nhsggc.org.uk · active foot disease definition: presence of active ulceration,...

THE DIABETIC FOOT

Gillian Harkin

Podiatrist

Foot Problems In Diabetes

• Ischaemia

• Neuropathy

• Foot Deformity

• Combination

• Infection

Ischaemic Foot

• Absent Pulses

• Cold

• Cyanotic/pale

• Dry, shiny skin

• Lack of hair

• Atrophied nails

• Intermittent Claudication

• Rest pain

• Gangrene

Vascular Assessment

• Test

– Palpate Pulses

– Doppler

– Capillary Refill Time

• Observe

– Skin Quality Changes

– Temperature

Gradient

– Colour Changes

Neuropathy

SENSORY

10g monofilament

MOTOR

Visual

AUTONOMIC

Visual

Peripheral Neuropathy

Sensory Neuropathy

• Numb

• Tingling/shooting

pains/pins and

needles

• Charcot Foot

Motor Neuropathy

• Deformity

• High pressure areas

• High medial

longitudinal arch

• Claw toes

• Callus/ corns

Autonomic Neuropathy

• Warm

• Dry skin

• Fissures

• AV shunting

• Prominent veins

• Oedema

• Palpable, bounding

pulses

Neurological assessment

Test

• Vibration perception

• 10g monofilament

Observe

• Foot deformity

• Skin changes

Foot Deformity

• Hallux Valgus

• Pes Cavus

• Pes planus

• Hallux rigidus

• Lesser Toe

Deformities

• Osteoarthritis

• Charcot Foot

Charcot Foot

• Condition causing weakness

of the bones in the foot

• Can occur when there is

significant neuropathy

• Bones fragment, fracture,

dislocate followed by new

bone formation

• Symptoms may include:

• Warm to touch

• Redness in the area

• Swelling of the foot

• Pain

Additional Risk Factors

• History of ulcers

• History of amputation

• Callus

• Ill-fitting footwear

• Visual impairment

• Smoking/ alcohol intake/

obesity

• Poor glycaemic control

• Other medication e.g. Steroid

therapy

Diabetic Foot Screening Objectives

• To identify a patient with a foot problem

• To indicate those at risk of developing

problems

• To make a diagnosis based on the result

• To develop a treatment plan

• To refer to other disciplines if necessary

• To compare with previous examinations

Why Use SCI – Diabetes ?

• Quick, simple & easy to use

• Standardise screening

across NHS Scotland

• Takes into account all the

main risk factors

• Automatic risk stratification /

calculation

• Prevents duplication

• Secure, shared information

• Onward referral when

required

5%

5% Active ulcers or Infection.

Revascularisation or Amputation Multidisciplinary foot care team management15% High risk

Intensive ‘foot protection’’

20% Moderate risk

Regular ‘foot protection’

The Pyramid of Foot Care for a population of people with Diabetes

(Young 2006)

20%

15%

60% Low risk

Routine annual screening

60%

RISK TRIANGLE

‘TRAFFIC LIGHTS’

Low RiskDefinition: No risk factors

present e.g. no loss of

sensation, no signs of

peripheral vascular disease

and no other risk factors.

Action: Annual screening by a

suitably trained Health Care

Professional. Agreed self

management plan. Provides

written and verbal education with

emergency contact numbers.

Appropriate access to podiatrist

if/when required.

Moderate RiskDefinition: One risk factor present e.g.

Loss of sensation or signs of peripheral

vascular disease without callus or

deformity.

Action: Annual assessment by a

podiatrist. Agreed and tailored

management/treatment plan by

podiatrist according to patient

needs. Provide written and

verbal education with

emergency contact numbers.

High Risk

Definition: Previous ulceration or

amputation or more than one risk

factor present e.g. Loss of sensation

or signs of peripheral vascular

disease without callus or deformity

Action: Annual assessment by a

podiatrist. Agreed and tailored

management/treatment plan by

specialist podiatrist according to patient

needs. Provide written and verbal

education with emergency contact

numbers. Referral for specialists

intervention if/when required.

Active Foot Disease

Definition: Presence of active ulceration,

spreading infection, critical ischaemia,

gangrene or unexplained hot, red,

swollen foot with or without the presence

of pain.

Action: Rapid referral to and management

by a member of a Multidisciplinary Foot

Team. Agreed and tailored

management/treatment plan according to

patient needs. Provide written and verbal

education with emergency contact numbers.

Referral for specialist intervention when

required.

Diabetes Referral PathwayActive Foot Disease

Active Diabetic Foot

Disease Present

Refer to MDFC at

same site as diabetes

care provided

Does the patient

attend a secondary

care site for diabetes

management

Refer to local diabetes

foot clinic

Refer to Primary Care

Podiatry

No

Yes

No

Yes

Other Resources

• Leaflets, (in various languages)

– www.diabetesinscotland.org.uk

– www.mydiabetesmyway.scot.nhs.uk

• SCI-Diabetes DVD and Hand Book

– www.diabetesframe.org

• Local Specialist Diabetic Podiatrist

• Multi-disciplinary Diabetic Foot Clinic

– GG-UHB@diabetesfootvictoria@nhs.net

– GG-UHB@diabetesfootSGH@nhs.net

Thank You