1. Slides current until 2008 Diabetic neuropathy Wound healing

2. Diabetic neuropathy Wound healing Curriculum Module III-7C Slide 2 of 31 Slides current until 2008 The diabetic foot Neuropathy – principal problem Vascular disease – secondary

3. Diabetic neuropathy Wound healing Curriculum Module III-7C Slide 3 of 31 Slides current until 2008 Four types of ulcers Neuropathic ulcers Ischaemic ulcers Neuroischaemic ulcers Venous ulcers

4. Diabetic neuropathy Wound healing Curriculum Module III-7C Slide 4 of 31 Slides current until 2008 Determine aetiology Neuropathic? Vascular? Mixed? predominant pathology? Determine wound management Act quickly

5. Diabetic neuropathy Wound healing Curriculum Module III-7C Slide 5 of 31 Slides current until 2008 Neuropathic ulcers Area of pressure Callus Red granulating base Low-to-moderately exudative Bounding pulses Painless

6. Diabetic neuropathy Wound healing Curriculum Module III-7C Slide 6 of 31 Slides current until 2008 Intrinsic – biomechanical

7. Diabetic neuropathy Wound healing Curriculum Module III-7C Slide 7 of 31 Slides current until 2008 Extrinsic – thermal

8. Diabetic neuropathy Wound healing Curriculum Module III-7C Slide 8 of 31 Slides current until 2008 Extrinsic – footwear

9. Diabetic neuropathy Wound healing Curriculum Module III-7C Slide 9 of 31 Slides current until 2008 Extrinsic – chemical

10. Diabetic neuropathy Wound healing Curriculum Module III-7C Slide 10 of 31 Slides current until 2008 Management of neuropathic ulcers Treat infection Debridement of callus Reduce pressure Restrict walking Dressings

11. Diabetic neuropathy Wound healing Curriculum Module III-7C Slide 11 of 31 Slides current until 2008 Pre- and post-debridement

12. Diabetic neuropathy Wound healing Curriculum Module III-7C Slide 12 of 31 Slides current until 2008 Felt deflection Reduces pressure by 61% Simple and cheap Replace weekly Impractical for exudating ulcers Risk of tinea/skin tears

13. Diabetic neuropathy Wound healing Curriculum Module III-7C Slide 13 of 31 Slides current until 2008 Ulcer healing with felt deflective padding Week 1: pre-debridement Week 1: post-debridement Week 3 Week 6: healed

14. Diabetic neuropathy Wound healing Curriculum Module III-7C Slide 14 of 31 Slides current until 2008 Pre-fabricated casts Simple to use Will not fit all feet Removable Less effective in maintaining foot shape

15. Diabetic neuropathy Wound healing Curriculum Module III-7C Slide 15 of 31 Slides current until 2008 Ischaemic ulcer On toes and foot margins Pale granulation, sloughy tissue or eschar Dry with irregular borders Painful Pulses weak or impalpable

16. Diabetic neuropathy Wound healing Curriculum Module III-7C Slide 16 of 31 Slides current until 2008 Management of ischaemic ulcers Vascular assessment and treatment Treat infection Pain management Dressings Avoid compression/bandaging

17. Diabetic neuropathy Wound healing Curriculum Module III-7C Slide 17 of 31 Slides current until 2008 Treatment goals Control infection Improve blood supply Optimize wound healing environment Protect wound from trauma

18. Diabetic neuropathy Wound healing Curriculum Module III-7C Slide 18 of 31 Slides current until 2008 Neuro-ischaemic ulcer Mixed neuropathic and vascular processes One process more dominant Need to assess

19. Diabetic neuropathy Wound healing Curriculum Module III-7C Slide 19 of 31 Slides current until 2008 Practice tips: neuropathic ulcers Foams 2 cm larger than the wound Use gels sparingly Keep foot dry – wash separately Do not use occlusive dressings Extra pads increase pressure and occlude the wound

20. Diabetic neuropathy Wound healing Curriculum Module III-7C Slide 20 of 31 Slides current until 2008 Practice tips: ischaemic ulcers Gels contraindicated in the presence of ischaemia Do not debride Do not use compression Keep foot dry in shower and wash separately Be very careful with tapes to prevent skin tears

21. Diabetic neuropathy Wound healing Curriculum Module III-7C Slide 21 of 31 Slides current until 2008 Foot infection Swelling, redness, heat Odour from ulcer Increase in exudate Failure to heal Elevated blood glucose levels Pain may not be present if the person has loss of sensation. Signs of inflammation may be absent in people with severe ischaemia.

22. Diabetic neuropathy Wound healing Curriculum Module III-7C Slide 22 of 31 Slides current until 2008 In diabetes, clinical signs may be masked leading to delayed diagnosis of infection.

23. Diabetic neuropathy Wound healing Curriculum Module III-7C Slide 23 of 31 Slides current until 2008 Do not withhold antibiotics until results of culture available Rely on clinical judgement

24. Diabetic neuropathy Wound healing Curriculum Module III-7C Slide 24 of 31 Slides current until 2008 Antibiotic treatment is an essential aspect of treating diabetic foot ulcers – maintain until ulcer has healed. Depending on clinical response, frequent changes and long-term antibiotics may be required.

25. Diabetic neuropathy Wound healing Curriculum Module III-7C Slide 25 of 31 Slides current until 2008 Foot infection Ulcer = risk of infection Osteomyelitis (sausage toe) Amputation

26. Diabetic neuropathy Wound healing Curriculum Module III-7C Slide 26 of 31 Slides current until 2008 Treatment of osteomyelitis Antibiotics –minimum of 3 months until there is evidence of healing on x-ray or scan Infected bones may need to be removed surgically

27. Diabetic neuropathy Wound healing Curriculum Module III-7C Slide 27 of 31 Slides current until 2008 Prevention of the diabetic foot disease Primary prevention No successful clinical trials Metabolic control Smoking cessation Secondary prevention Identify high risk feet Foot education Foot care Management of active foot problems (ulceration)

28. Diabetic neuropathy Wound healing Curriculum Module III-7C Slide 28 of 31 Slides current until 2008 Key points Assess Determine aetiology Arrange appropriate wound management

29. Diabetic neuropathy Wound healing Curriculum Module III-7c Slide 29 of 31 ACTIVITY Slides current until 2008 Case study 70-year old man Type 2 diabetes Diabetes for 35 years Smoker for 35 years

30. Diabetic neuropathy Wound healing Curriculum Module III-7c Slide 30 of 31 ACTIVITY Slides current until 2008 Case study Pulses absent ABI’s Left - 0.69 Right - 0.71 Left 1st MPJ ulcer Right hallux (great toe) ulcer – had bypass now ABI improved to 1.00

31. Diabetic neuropathy Wound healing Curriculum Module III-7c Slide 31 of 31 ACTIVITY Slides current until 2008 Case study Biothesiometer –>50 volts Monofilament –cannot feel Reflexes –absent