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DM - FOOT EVALUATION IN THE PRIMARY CARE SETTING Bernadette Pendergraph, Gloria Sanchez, MDs Cindy Mayeda, RN Department of Family Medicine, Harbor-UCLA.

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Presentation on theme: "DM - FOOT EVALUATION IN THE PRIMARY CARE SETTING Bernadette Pendergraph, Gloria Sanchez, MDs Cindy Mayeda, RN Department of Family Medicine, Harbor-UCLA."— Presentation transcript:

1 DM - FOOT EVALUATION IN THE PRIMARY CARE SETTING Bernadette Pendergraph, Gloria Sanchez, MDs Cindy Mayeda, RN Department of Family Medicine, Harbor-UCLA An ounce of prevention is worth a pound of cure. – Benjamin Franklin

2 Learning Objectives Medical Knowledge Medical Knowledge a. Perform Comprehensive DM Foot Exam b. Implement ADA DM Foot Guidelines c. Classify DM Foot Ulcers Accurately d. List indications for imaging Patient Care Patient Care a. Offloading Devices for DM Ulcers b. Utilize consultants in timely fashion No conflicts of interest

3 Learning Objectives System Based Practice System Based Practice a. Utilize resources for patients b. Expedite pt work up & tx PRN Interpersonal & Communication Skills Interpersonal & Communication Skills a. Teach pts DM foot care & precautions b. Collaborate with HC team to examine & treat pts Professionalism Professionalism a. Take ownership of DM foot ulcer

4 IMPORTANCE OF FOOT EXAMS National Hospital Discharge survey 1996 86,000 with DM under went > 1 amputation National Hospital Discharge survey 1996 86,000 with DM under went > 1 amputation DM leading cause of amputation in lower extremities DM leading cause of amputation in lower extremities > 50% preventable > 50% preventable Triad: neuropathy, deformity, trauma Triad: neuropathy, deformity, trauma Absence of nerve and vascular complaints is not protective Absence of nerve and vascular complaints is not protective Incidence of: Incidence of: Foot ulcers up to 25% lifetime risk, annual risk 2% Foot ulcers up to 25% lifetime risk, annual risk 2% ~50% infected ~50% infected 14-24% amputation 14-24% amputation Lower extremity amputation Lower extremity amputation 50% in same/opposite extremity in 5 yrs. 50% in same/opposite extremity in 5 yrs. Mortality all cause at 5 yr 39-68% Mortality all cause at 5 yr 39-68%

5 IMPORTANCE OF FOOT EXAMS Healthy People 2020 goals Healthy People 2020 goals Increase # of persons receiving at least an annual foot exam Increase # of persons receiving at least an annual foot exam Decrease amputations related to DM Decrease amputations related to DM Ethnic risk for amputation per 10,000 persons with DM Ethnic risk for amputation per 10,000 persons with DM African-Americans 95.3 African-Americans 95.3 Hispanic 44.4 Hispanic 44.4 Caucasians 56 Caucasians 56

6 IMPORTANCE OF FOOT EXAMS % amputations related to DM % amputations related to DM Hispanics82.7 Hispanics82.7 African-Americans61.6 African-Americans61.6 Caucasians56.8 Caucasians56.8 Foot exam frequency Foot exam frequency By patient By patient Daily52% Daily52% Never22% Never22% By provider By provider Type 1 66% Type 1 66% Type 2 52% Type 2 52%

7 COST OF DM FOOT DISEASE Amputations > $1.1 billion Amputations > $1.1 billion Ulcer in male 40-65 y.o. $28,000 over 2 yr Ulcer in male 40-65 y.o. $28,000 over 2 yr

8 RISK FACTORS FOR AMPUTATION Arterial insufficiency: DM > 10 yrs, Tobacco use Arterial insufficiency: DM > 10 yrs, Tobacco use Disease control: high FBS, high A1c, duration = two fold increase Disease control: high FBS, high A1c, duration = two fold increase Sex: male Sex: male Eng Organ Damage: Eng Organ Damage: Retinopathy Retinopathy Nephropathy Nephropathy Cardiovascular disease Cardiovascular disease Peripheral neuropathy: absent Achilles reflex, decreased vibratory sensation = 2 x likely in amputees Peripheral neuropathy: absent Achilles reflex, decreased vibratory sensation = 2 x likely in amputees Abnormal gait 15x more likely to injure Abnormal gait 15x more likely to injure Abnormal monofilament exam 60% develoed ulcers, 21% amputations over 32 months Abnormal monofilament exam 60% develoed ulcers, 21% amputations over 32 months

9 RISK FACTORS FOR AMPUTATION Abnormal foot anatomy Abnormal foot anatomy Nail – Onycholysis, Ingrown Nail – Onycholysis, Ingrown Skin – Xerosis, Corn, Callus, Hair loss Skin – Xerosis, Corn, Callus, Hair loss Bone – Hallux valgus, hammer toes, prominent metatarsal heads, Charcot foot Bone – Hallux valgus, hammer toes, prominent metatarsal heads, Charcot foot Previous ulcer or amputations Previous ulcer or amputations Loss of monofilament perception – 18 fold increase risk of ulcer Loss of monofilament perception – 18 fold increase risk of ulcer

10 PRECIPITATING EVENTS FOR AMPUTATION Injury from new shoes Injury from new shoes Improper toe nail trimming Improper toe nail trimming Accidental wounds Accidental wounds Thermal injury Thermal injury 1/3 of injuries self induced in PVD 1/3 of injuries self induced in PVD

11 ADA GUIDELINES Everyone with DM gets a foot exam Everyone with DM gets a foot exam Starts at diagnosis Starts at diagnosis Frequency: At least annual – stratify high vs low risk Frequency: At least annual – stratify high vs low risk Visual inspection every visit if neuropathy Visual inspection every visit if neuropathy Prerequisite history Prerequisite history Previous ulceration, amputation, Charcot joint, vascular surgery, angioplasty, tobacco use Previous ulceration, amputation, Charcot joint, vascular surgery, angioplasty, tobacco use Symptoms of claudication or neuropathy Symptoms of claudication or neuropathy DM complications: renal, visual DM complications: renal, visual

12 ADA GUIDELINES FOR FOOT CARE Foot exam components Foot exam components Visual inspection: dermatologic, musculoskeletal, shoe Visual inspection: dermatologic, musculoskeletal, shoe Neurological assessment: 10g Monofilament + 1 of the following: Neurological assessment: 10g Monofilament + 1 of the following: Vibration Vibration Pinprick Pinprick Ankle reflexes Ankle reflexes VPT VPT Vascular: Pulses, consider ABI Vascular: Pulses, consider ABI

13 DERMATOLOGIC INSPECTION Nails Nails Shape/length Shape/length Ingrown, paronychia Ingrown, paronychia Onycholysis Onycholysis Skin Skin Xerosis Xerosis Callus/Corn/Ulcer Callus/Corn/Ulcer Temperature Temperature

14 MUSCULOSKELETAL ASSESSMENT Deformities Deformities Toe deformities-claw, hammer Toe deformities-claw, hammer Bunions Bunions Charcot foot Charcot foot

15 SHOE EVALUATION Look at the patients shoes (Are these shoes appropriate for these feet?) Look at the patients shoes (Are these shoes appropriate for these feet?) Type of material? Type of material? Good: canvas, suede, leather, elastic Good: canvas, suede, leather, elastic Bad: plastic Bad: plastic Any foreign objects? Any foreign objects? Depth appropriate? Depth appropriate? Width appropriate? Width appropriate? Size? Size? How old? How old?

16 NEUROLOGIC ASSESSMENT Peripheral neuropathy most common cause of DM foot ulceration Peripheral neuropathy most common cause of DM foot ulceration Identify loss of protective sensation (LOPS) Identify loss of protective sensation (LOPS) 10 g monofilament 10 g monofilament 128 Hz turning fork: vibratory sensation-tip of great toe bilaterally 128 Hz turning fork: vibratory sensation-tip of great toe bilaterally Pinprick: disposable pin proximal to nail of great toe Pinprick: disposable pin proximal to nail of great toe Ankle reflexes Ankle reflexes Vibration perception threshold testing: mean of 3 readings; VPT > 25V Vibration perception threshold testing: mean of 3 readings; VPT > 25V

17 MONOFILAMENT TESTING Patient should close the eyes Check patient on proximal site to demonstrate Instruct the patient to tell you when he feels the monofilament Push the monofilament until it bends, then hold for 1-2 seconds Lift the monofilament from skin Retest the area where the patient did not feel the monofilament (Avoid callus) Mark the areas of the foot using a plus sign (+) if they can feel the monofilament and a minus sign (-) if they cannot

18 VASCULAR ASSESSMENT PAD is a component cause in 1/3 of ulcers PAD is a component cause in 1/3 of ulcers Risk factor for recurrent wound Risk factor for recurrent wound Palpate dorsalis pedis and posterior tibialis Palpate dorsalis pedis and posterior tibialis If pulses are absent or symptoms of PAD, do ABI If pulses are absent or symptoms of PAD, do ABI DM > 50 yo DM > 50 yo DM < 50 with multiple PAD risk factors DM < 50 with multiple PAD risk factors

19 ABI Readings Abnormal>1.2 (medial calcinosis) Abnormal>1.2 (medial calcinosis) Normal0.9-1.2 Normal0.9-1.2 Moderate Vascular Dz0.4-0.8 Moderate Vascular Dz0.4-0.8 Severe Vascular Dz<0.4 Severe Vascular Dz<0.4

20 TOE PRESSURE TESTING (TBI) Consider doing if ABI > 1.2 Consider doing if ABI > 1.2 Cut off are different than ABI Cut off are different than ABI TBI > 0.5 or > 70 mm Hg = normal TBI > 0.5 or > 70 mm Hg = normal TBI < 0.2 or < 30mm Hg = severely ischemic TBI < 0.2 or < 30mm Hg = severely ischemic

21 RISK CLASSIFICATION

22 FOOT CONDITIONS TO WATCH OUT FOR Diabetic foot infections: inframalleolar infection in a person with DM Diabetic foot infections: inframalleolar infection in a person with DM Acute: Predominantly g+ cocci Acute: Predominantly g+ cocci Clindamycin Clindamycin Keflex Keflex Bactrim Bactrim Augmentin Augmentin Chronic: g-rods Chronic: g-rods 2 nd generation cephalosporin 2 nd generation cephalosporin Linezolid Linezolid Daptomycin Daptomycin

23 DIABETIC FOOT INFECTIONS Ischemia: obligate anaerobes Ischemia: obligate anaerobes Vascular evaluation Vascular evaluation Fluoroquinolone + clindamycin Fluoroquinolone + clindamycin Imipenem Imipenem Vancomycin + Ceftazidime + metronidazole Vancomycin + Ceftazidime + metronidazole

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25 ULCERS Venous stasis ulcer Venous stasis ulcer Medial malleolar area Medial malleolar area Irregular borders Irregular borders Red-brown staining Red-brown staining Lower extremity edema/varicose veins Lower extremity edema/varicose veins Arterial insufficiency ulcer Arterial insufficiency ulcer Tip of the toe Tip of the toe Punched out (clear demarcation) Punched out (clear demarcation) Pale, dry base without edema Pale, dry base without edema

26 WAGNER ULCER CLASSIFICATION Grade 0 = no ulcer in high risk foot Grade 1 = ulcer involving full skin thickness Grade 2 = ulcer to ligament and muscle Grade 3 = ulcer with cellulitis/abscess Grade 4 = localized gangrene Grade 5 = extensive gangrene involving whole foot

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28 ULCER TREATMENT Patients should never walk out in the same shoe wear they walked in… Patients should never walk out in the same shoe wear they walked in… Offload ulcer Offload ulcer Modify shoe insert – cut out area under ulcer Modify shoe insert – cut out area under ulcer Healing boot Healing boot Total contact cast Total contact cast Assess vascularity Assess vascularity Wound care Wound care Inciting event – shoe, foreign body = xray Inciting event – shoe, foreign body = xray Debridement Debridement Assess if Infected Assess if Infected Close follow-up Close follow-up

29 FOOT CONDITIONS Charcot foot Charcot foot Neuropathic joint – progressive destruction of bone and soft tissues at weight bearing joints Neuropathic joint – progressive destruction of bone and soft tissues at weight bearing joints Rocker bottom foot with continued ambulation Rocker bottom foot with continued ambulation Incidence in DM: 0.15- 2.5% Incidence in DM: 0.15- 2.5% Recurrence 5% Recurrence 5% Bilateral disease 10% Bilateral disease 10% Men = Women Men = Women

30

31 PATHOGENESIS OF CHARCOT

32 STAGING

33 WHICH ONE IS CHARCOT FOOT?

34 NORMAL FOOT

35 CHARCOT FOOT Acute Acute Inflammatory: swelling, increased temperature (3-7°F), redness, bony resorption Inflammatory: swelling, increased temperature (3-7°F), redness, bony resorption Intact skin and pulses Intact skin and pulses Insensate foot Insensate foot Treatment Treatment Immobilization: total contact cast Immobilization: total contact cast Reduce stress: non-weight bearing Reduce stress: non-weight bearing r/o infection r/o infection Chronic Chronic Protection: orthotics, surgery Protection: orthotics, surgery

36 TREATMENT OVERVIEW

37 OTHER ORTHOSIS Charcot foot Charcot foot AFO: offload bottom of foot and reduce ankle motion AFO: offload bottom of foot and reduce ankle motion Total contact cast: transfer weight away from foot Total contact cast: transfer weight away from foot Pneumatic walker brace Pneumatic walker brace

38 OTHER ORTHOSIS Charcot foot Charcot foot AFO: offload bottom of foot and reduce ankle motion AFO: offload bottom of foot and reduce ankle motion Total contact cast: transfer weight away from foot Total contact cast: transfer weight away from foot Toe amputations Toe amputations Toe filler Toe filler Forefoot amputations: custom shoes Forefoot amputations: custom shoes

39 Achilles lengthening Achilles lengthening Transmetatarsal amputation Transmetatarsal amputation

40 SHOE PRESCRIPTIONS Healing shoes: post op or heat molded shoes Healing shoes: post op or heat molded shoes Depth in-lay: toe deformities, prescription inserts Depth in-lay: toe deformities, prescription inserts Extra wide: bunions Extra wide: bunions Rocker sole: reduce pressure on metatarsal heads; hallux rigidis Rocker sole: reduce pressure on metatarsal heads; hallux rigidis Custom molded: severe feet deformities Custom molded: severe feet deformities

41 SHOE PRESCRIPTIONS Medicare covers custom shoes for persons with DM, in a comprehensive DM care program and one of the following: Medicare covers custom shoes for persons with DM, in a comprehensive DM care program and one of the following: H/o amputation H/o amputation H/o ulcer H/o ulcer H/o preulcerative callus H/o preulcerative callus Peripheral neuropathy with callus Peripheral neuropathy with callus Poor circulation Poor circulation Foot deformity Foot deformity Products for the year Products for the year One pair of depth shoes with 3 inserts One pair of depth shoes with 3 inserts One pair of custom-molded shoes/inserts with 2 inserts One pair of custom-molded shoes/inserts with 2 inserts

42 FOOT CARE INSTRUCTIONS Good sugar control Good sugar control Daily visual exam Daily visual exam Moisturize your feet Moisturize your feet Appropriate shoe wear – never barefoot, no open toe box Appropriate shoe wear – never barefoot, no open toe box Firm heel counters and uppers – to prevent excessive motion and rolling Firm heel counters and uppers – to prevent excessive motion and rolling A firm and wide outsole – to provide a stable base for the foot A firm and wide outsole – to provide a stable base for the foot An extra-depth construction with a removable inlay – to provide added cushion; allow room for a custom foot orthosis An extra-depth construction with a removable inlay – to provide added cushion; allow room for a custom foot orthosis

43 HOW TO DEAL WITH PROBLEMS Thermal injury Thermal injury Shoe color (8-13°) Shoe color (8-13°) Bony abnormalities Bony abnormalities Mild deformities: Appropriate depth and width Mild deformities: Appropriate depth and width Athletic shoes Athletic shoes Soft insoles: plastazote/urethrane viscoelastic Soft insoles: plastazote/urethrane viscoelastic Laces or Velco strap Laces or Velco strap Severe deformities or amputation: Shoe prescription Severe deformities or amputation: Shoe prescription Relieve excessive pressure Relieve excessive pressure Decrease shock, sheer pressures Decrease shock, sheer pressures Accommodate, stabilize, and support deformities Accommodate, stabilize, and support deformities

44 Medicare pays 80% of what is allowed Depth shoes $126 Custom molded shoes $378 Inserts $64

45 RISK FACTORS FOR FOOT ULCER Poor glycemic control Poor glycemic control Visual impairment Visual impairment Previous foot ulcer/amputation Previous foot ulcer/amputation Peripheral neuropathy Peripheral neuropathy PAD PAD Foot deformity Foot deformity DM nephropathy DM nephropathy Cigarette smoking Cigarette smoking

46 High risk: amputation, ulcer High risk: amputation, ulcer Elevated A1c doubles risk of amputation Elevated A1c doubles risk of amputation


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