DIBETIC FOOT ULCER

ETIO-PATHOGENESIS & MANAGEMENT

DR.ARUN BAL

S.L.RAHEJA HOSPITAL

METHOD OF OFF-LOADING

• BEDREST

• CRUCTHES

• WHEELCHAIR

• SPECIAL FOOTWEAR

• CONTACT CASTING

MECHANISM OF INJURY

• DIRECT PENETRATION OF SKIN

• SMALL AMOUNT OF FORCE SUSTAINED OVER A PERIOD OF TIME

• MODERATE AMOUNT OF REPATATIVE FORCE

INDICATION OF WORSENING INFECTION

• INCREASED DRAINAGE

• INCREASED ERYTHEMA

• SUDDEN INCREASE IN PAIN

• INCREASED WARMTH

• FOUL ODOUR

• LYMPHANGITIS

INDICATION OF WORSENING INFECTION(CONT)

• INCREASED BLOOD GLUCOSE LEVEL

• INCREASED WBC LEVEL

• INCREASED E.S.R

• REDUCED QUADRICEPS ACTION

• PERSISTANT ANOREXIA

• HIGH SERUM CREATININE

• OFF LOADING OF AFFECTED FOOT

WHAT CAUSES HIGH PLANTAR PRESSURE?

• DISPLACEMENT OF METATARSAL CUSHION DISTALLY

• NON ENZYMATIC GLYCOLISATION

• LIMITATION OF MOVEMENT OF 1ST MTP JOINT

• REDUCED ELASTICITY

WHAT CAUSES HIGH PLANTAR PRESSURE?

• DECREASED SUBTALAR JOINT MOVEMENT

• EXCESSIVE PLANTAR KERATOSIS

• THICKENING OF SESMOID

• ADHESIONS & SCAR TISSUE

HOW DOES FOOT INJURY OCCUR?

• PEAK PLANTAR PRESSURE:1340kPa

• SYSTOLIC BP 120 mm OF H:15 kPa

• CAPILLARY PRESSURE :6 kPa

• DELAYED/ABSENT RECOVERY FROM ISCHAEMIA

• DELAYED/ABSENT RECOVERY OF NORMAL TISSUE OXYGEN CONC.

HOW DOES FOOT INJRY OCCUR?

• REPATATIVE MODERATE FORCE

• INFLAMMATION

• ERYTHEMA AND WARMTH

• COLLECTION OF EXUDATE

• BLISTER FORMATION

• BREAKDOWN OF SKIN --- ULCER

NEED FOR PROMPT TREATMENT OF FOOT ULCER• 85% OF DIABETIC FOOT

AMPUTATIONS ARE DUE TO INADEQUATELY TREATED FOOT ULCER

• 30-50% AMPUTEES REQUIRE CONTRALATERAL AMPUTATION IN 3 YEARS

NEED FOR PROMPT TREATMENT IF FOOT ULCER

• 10% MORTALITY IN THREE YEARS IN AMPUTEES

• ECONOMIC LOSS TO FAMILY AND SOCIETY

• 22% REQUIRE IPSILATERAL HIGHER AMPUTATION

FOOT ULCER ASSESSMENT

• PERIWOUND ERYTHEMA

• PERIWOUND ODEMA

• WOUND PURULENCE

• WOUND FIBRIN

• LIMB PITTING ODEMA

• LIMB BRAWNY ODEMA

FOOT ULCER ASSESSMENT

• WOUND GRANULATION

• VASCULAR STATUS

• WOUND MEASUREMENT

• OSTEOMYLITIS & TENOSYNOVITIS

MECHANISM OF INJURY IN DIABETIC FOOT

• NORMAL STRESS

• SHEAR STRESS

• FATIGUE

• STRESS CONCENTRATION

• ELATICITY

PRIMARY TREATMENT OF DIABETIC FOOT ULCER

• EVALUATION

• METABOLIC CONTROL

• DEBRIDEMENT

• BACTERIAL CULTURE

PRIMARY TREATMENT OF DIABETIC FOOT ULCER

• PARENTERAL ANTIBIOTICS

• OFF LOADING OF AFFECTED FOOT

• REVASCULARIZATION

• CORRECT FOOTWEAR

OBJECTIVES OF DIABETIC FOOT WEAR

• REDUCTION OF EXCESSIVE PLANTAR PRESSURE

• REDUCTION OF SHOCK

• REDUCTION OF SHEAR

• ACCOMODATION OF DEFORMITY

• STABALIZATION OF DEFORMITY

• LIMITATION OF JOINT MOVEMENT

OBJECTIVES OF DIABETIC FOOTWEAR

• WIDE TOEBOX• EXTRA DEPTH• SOFT UPPERS• MCR/PLASTAZOAT INSOLE• INSOLE WING PAD• ORTHOWDGE CORRECTION• WELL FITTING SOCKS

SURGERY FOR DIABETIC FOOT ULCER

• PROPHYLACTIC

• THERAPEUTIC

PRPHYLACTIC SURGERY FOR DIABETIC FOOT ULCER

• METATARSAL OSTEOTOMY

• METATARSAL HEAD RESECTION

• SESMOIDECTOMY

• DIGITAL ARTHROPLASTY

• BUNIONECTOMY

• LOCAL FLAPS