1. Angela Walker Diabetes Specialist Podiatrist
The Diabetic Foot
Angela Walker
Diabetes Specialist Podiatrist

2. “Why Worry …?”
Approximately 15% of all people with diabetes will be affected by foot ulcer during their lifetime;
85% of diabetes-related amputations are preceded by foot ulcers (International Diabetes Federation) ;
Up to 70% of amputations are performed on people with Diabetes;
“Someone, somewhere, loses a leg because of diabetes every 30 seconds of everyday…”
Lancet. 2005;366:1674

3. Multifactorial Aetiology
Vascular: macro and microangiopathy results in poor skin quality, poor healing and potential for ulceration and amputation.
Neuropathy causes loss of sensation, potential for injury, infection, leading to ulceration and possible amputation.
Delayed immune response: any injury to the foot is a potential cause for concern.

4. Diabetic Ischaemia Micro-vascular and Macro-vascular
Pathology identical to non-diabetics
Earlier onset
Complications of high blood pressure, high
cholesterol and smoking are all amplified by
diabetes
1 Cigarette reduces peripheral blood flow by 30% for
1 hour.

5. Skin Colour
& Temperature
History of
Intermittent
Claudication
Faint or
Absent Pulses
Reduced or
Absent Hair
Anhydrosis
& Fissures
Changes in
Nail & Rate
of Growth
Loss of Wrinkling of
Skin Around Joints

7. Peripheral Neuropathy
Dysfunction of sensory, motor and autonomic nerves:
Loss of protective pain sensation – increased susceptibility to foot ulceration
Motor – high medial longitudinal arch, clawed toes, prominent metatarsals
Autonomic – dry, fissured skin, sweat loss, distended dorsal veins

8. “Cramping, Tingling, Aching, Burning, Numbness”
Well nourished tissue
“Cramping, Tingling, Aching, Burning, Numbness”
Diminished / absent sensation

9. Callus at pressure points
Good DP and PT pulses
Charcot Deformities
Callus at pressure points
Painless ulcerations

10. Bilateral Charcot

11. Differential Diagnosis
Neuropathic
Warm
Normal colour
Palpable pulses
Skin well nourished
Callus at pressure points
Ulceration plantar
Neuroischaemic
Cool
Pale
Pulses diminished/ absent
Skin thin shiny no hair
No callus fissuring at bony
prominences
Ulcers peripheral

12. Pressure Ulceration
1. Callus formation
2. Subcutaneous
haemorrhage
3. Breakdown of skin
4. Deep foot infection with osteomyelitis

13. Osteomyelitis
Approximately 25% of foot ulcers will be affected by osteomyelitis (Young, Diabetic Foot Journal, 2008);
Surgery is not always necessary especially in patients without life or limb-threatening infections;
82% of patients studied by Game and Jeffcoate (Diabetologia, 2008) were able to avoid surgery with one or more courses of antibiotics.

16. Foot problems can be Deceptive
Is the diabetic ulcer infected?
Compare the temperature of both legs
Check blood glucose levels
Pain is serious in the neuropathic foot
Localised superficial infection is probably the tip of the iceberg
Healed wounds need appropriate protection
to prevent recurrence

17. Debridement
Neuropathic ulcers – need to be debrided as soon as possible to determine the depth of the ulcer and removal of necrotic tissue
Ischaemic ulcers – should not be debrided unless signs of infection present.

18. Before Sharp Debridement

19. After Sharp Debridement

22. Wound Dressing Aseptic technique;
Change dressings daily, more regularly when strike through noted on dressing;
Diabetic Foot wounds should be kept dry and clean at all times;
Do NOT soak the foot or bath/shower the patient;
Apply saline with gauze to clean wound surface.

23. Wound Dressings cont’d
Do NOT use hydrocolloid dressing as occlude and macerate the wound;
Simple wound dressing over ulcer site and secured;
Offload with appropriate foot wear/bed rest/turn patient regularly;
Review wound regularly and refer early if wound deteriorates;
Antibiotics?

24. The Cycle of Diabetic Infections
High blood sugar inhibits body fighting infection
Infection raises blood sugar
The Cycle of Diabetic Infections
Infection gets worse

25. Criteria for Wound Dressing Selection
Does the dressing:
Stay intact & in-situ?
Prevent leakage?
Cause maceration/allergy
or sensitivity?
Reduce pain?
Reduce odour?
Is the dressing:
Comfortable, conformable,
flexible?
Suitable for leaving in
place for the duration?
Easy to remove?
Easy to use?
Cost effective?

26. Who to refer to the Diabetes Specialists in WPH
New Ulceration;
New Swelling;
New Discoloration over all or part of the foot;
People with painful leg and foot symptoms whose diabetic control is poor;
Deterioration of a presenting wound:
↑Odour ↑Discharge ↑Redness ↑Pain ↑Swelling ↑Feeling unwell
Suspected Charcot – Plaster Nurse.

28. Where to Refer Diabetes Specialist Team: Dr Dove/Dr Akinsola
Ward Ext ???
Tissue Viability Nursing Team Ext ???
Vascular Team Ext ???
Plaster Room Ext ???
Podiatry Department Ext 4221
(Fax referral: stating Patient Diabetic with active ulcer)

29. On Discharge…..
Acute problem contact Diabetes Centre Podiatry, King Edward VII Hospital by:
Fax on ext 6624.
Patient with diabetic complications. Referral to Community Podiatry Clinics based in Slough, Windsor, Ascot, Bracknell, Langley.
For type 1 or type 2 patient education or advice send for group education via the Diabetes Centre these Education Sessions are held in Community locations.

30. Summary of Care Planning
Good glycaemic control
Offloading pressure
Safe removal of callus
Safe removal of slough, necrotic tissue
Treat infection
Allow drainage of exudate
Encourage patient compliance/patient education
Best form of treatment is prevention

31. Any Questions?