Diabetic foot Thongchai Pratipanawatr MD.

Site of Diabetic foot ulcers Site% Toe51 Plantar metatatarsal and mid foot 28 Dorsum of foot14 Multiple ulcers7

Outcome of Diabetic foot ulcers Outcome% Reepithelization/primary healing 63 Amputation24 Death13

Diabetic foot ulcer Neuropathic foot ulcer Ishemic foot ulcer Mixed ishemic-neuropathic

Neuropathic foot ulcer

Risk factors of foot ulcers Diabetic neuropathy increases risk of foot ulcer and amputation. Neuropathy1.7-folds Deformity12-folds Previous history of ulcer 36-fold

Distal sensory neuropathy Loss pain, temperature And fine touch sensation burning sensation Vibration, Position sense, Touch/pressure Motor: intrinsic muscle Small fiber Large fiber

Distal sensory neuropathy Diagnosis 10 gm monofilament: small fiber 128 Hz tuning fork: large fiber Motor deformity: large fiber

Sensory neuropathy Loss of protective sensation 5.07 (10 gram) Monofilament

Area of examination

Deformity Abnormal Foot pressure

Deformity Claw toes

Neuropathic foot ulcer Loss of sensation Deformity Callous formation Callous rupture Foot ulcer Infection

Diabetic foot ulcer Insensitive foot Inappropriate shoe (too tight) Deformity Ischemic foot ulcer

Insensitive foot

Insensitive foot examination ExaminationJustification GeneralInspect for possible ulceration SensoryTest sensation TemperatureLocal temp increase more than 2 C indicates of infection ShoesInspect foot ware MuscleMuscle deformaty

Neuropathic foot ulcer Loss of sensation Deformity Callous formation Callous rupture Foot ulcer Infection

Claw toes Deformity

Hammer toes Deformity

21 Callous

22 Ulcer

Chronic ulcer with osteomyelitis Osteolyticbone

Charcot’s foot

Acute Charcot’s foot Chronic Charcot’s foot

Charcot’s foot

Chacort’s deformity

Others neuropathic ulcer

Too tight shoe

Ishemic foot ulcer

Ischemic foot ulcer

Diabetic foot care

Risk factors of foot ulcers Diabetic neuropathy increases risk of foot ulcer and amputation. Neuropathy1.7-folds Deformity12-folds Previous history of ulcer 36-fold

Management category RiskSensationDeformityHx of ulcer 0PresentNo 1absentNo 2absentYesNo 3absentYes

Management category RiskManagment 0Foot clinic one a year; foot education 1Foot clinic every 6 months, appropriated footwear and soft insole 2Foot clinic every 3 months, custom- molded orthotic devices 3Foot clinic every 1-2 months, custom- molded orthotic devices

Foot education

Daily cleaning  

Skin & nail care

46 ผิวแห้ง - แตก

Appropriated footwear and soft insole

Proper shoes design

Proper shoes &soft insole

เลือกรองเท้าที่เหมาะสมกับเท้าไม่คับหรือหลวมจนเกินไป

รองเท้าที่ไม่เหมาะสมกับเท้า

Custom-molded orthotic devices

Soft inserts

Mold insoles

Total contact insole

Foot wear

57 Callous

58 Callous

Diabetic wound care

Depth-ischemia classification GradeDefinition 0At risk (previous ulcer or neuropathy with deformity 1Superficial ulcer, no infection 2Deep ulceration exposing tendon or joint (with or without infection) 3Extensive ulceration with expose bone or deep infections Depth classification

Depth-ischemia classification

GradeDefinition ANot ischemia BIschemia without gangrene CPartial (forefoot) gangrene of the foot DComplete foot gangrene Ischemia classification

Depth-ischemia classification

GradeDefinition 0At risk (previous ulcer or neuropathy with deformity 1Superficial ulcer, no infection 2Deep ulceration exposing tendon or joint (with or without infection) 3Extensive ulceration with expose bone or deep infections Depth classification

Depth-ischemia classification GradeIntervension 0Patient education and appropriated foot ware 1External pressure relief 2And surgical debridement (antibiotic) 3And antibiotic; amputaiton may be Depth classification

Off-loading Total contact cast (TCC) -gold standard Prefabricated pneumatic walking brace ( Air cast ) Half-shoes Crutches,Walkers and Wheelchairs Bed rest

Total contact cast

Air cast

Half shoe

Modified/custom shoes/orthoses

Surgical intervenion Debridement Amputation Osteotomy Bone stabilization Tendon tranfer or Tenotomy Achilles tendon lengthening tendon etc.

Depth-ischemia classification GradeDefinition ANot ischemia BIschemia without gangrene CPartial (forefoot) gangrene of the foot DComplete foot gangrene Ischemia classification

Vascular screening ♦ Hair loss ♦ Color ♦ Baked potato skin ♦ Capillary filling time ♦ Temperature ♦ Pulses ♦ Ankle brachial index (ABI)

Thank you