Diabetes Mellitus Foot Syndrome Clinical features OKONYIA NOSARIEMEN LILIAN SENIOR REGISTRAR, EDM UNIT, LUTH

OUTLINE Introduction Clinical features -History -Examination Grading Diff. diagnosis

INTRODUCTION diabetic foot - exhibits any pathology that results directly from DM or any of its chronic complications. DMFS- different aetiologies, diabetic foot pathologies, clinical picture The most serious foot complications in diabetes -Ischaemia -Infection -Neuropathic osteoarthropathy Umbrella termCommon to all: foot injury in DMFS can result in complications that may lead to amputation if treatment is delayed or ineffective.

INTRODUCTION Evaluated at these levels: Individual Lower limb/foot Ulcer

HISTORY Ulcer Location, duration Healing progression Constitutional symptoms, Infection severity Precipitants- trauma, boil, fissures, pedicure, tinea pedis Inappropriate footwear, Bare foot walking DM History Duration of DM Glycaemic control -Infection is diagnosed by the presence of signs and/or symptoms of inflammation, but these may be blunted by neuropathy or ischemia, -systemic findings (e.g. fever, increased white blood count) are often absent. -Infections should be classified as mild (superficial with minimal cellulitis), moderate (deeper or more extensive), or severe (accompanied by systemic signs of sepsis).

HISTORY Past history Vascular symptoms ulceration amputation Charcot joint vascular surgery, angioplasty cigarette smoking Neuropathic symptoms Positive negative claudication rest pain Non healing ulcer Other diabetes complications: -Macrovascular -Microvascular positive (e.g., burning shooting pain, electrical or sharp sensations, etc.) negative (e.g., numbness, feet feel dead) -many diabetic patients who undergo a lower extremity amputation have a very poor quality of life and have a 5-year mortality rate similar to that of some of the most deadly cancers -Also called Charcot joint or neuropathic joint, Charcot arthropathy is a progressive condition of the musculoskeletal system that is characterized by joint dislocations, pathologic fractures, and debilitating deformities. This disorder results in progressive destruction of bone and soft tissues at weight-bearing joints; in its most severe form, it may cause significant disruption of the bony architecture. Charcot arthropathy can occur at any joint; however, it occurs most commonly in the lower extremity, at the foot and ankle.

PHYSICAL EXAMINATION General appearance ± Ill-looking Hydration status fever Regional lymphadenopathy Anthropometry -weight, Height -BMI -WC, W/H ratio

PHYSICAL EXAMINATION Ulcer exam Derma. exam Location Size Depth Base Edge Infection, Discharge, sinus Skin appearance Oedema Cellulitis Nail appearance Fissures Inter-digital areas Gangrene skin status: color, thickness, dryness, cracking, sweating, calluses/blistering: -deformity, e.g., claw toes, prominent metatarsal heads, Charcot joint

PHYSICAL EXAMINATION

DIFFERENCE BETWEEN NEUROPATHIC & ISCHEMIC ULCER

PHYSICAL EXAMINATION CVS/Vascular exam Peripheral pulses -Dorsalis pedis pulse -Posterior tibial pulse ABI: Ankle systolic BP Brachial systolic BP BP Heart sounds -The ankle-brachial index (ABI) is an efficient tool for objectively documenting the presence of lower-extremity peripheral arterial disease (PAD) -Interpretation >1.30 Poorly compressible vessels, arterial calcification 0.90–1.30 Normal 0.60–0.89 Mild arterial obstruction 0.40–0.59 Moderate obstruction <0.04 Severe Obstruction

ABI CLASSIFICATION ≥1.30 Poorly compressible, arterial calcification 1-1.29 Normal range 0.91-0.99 Borderline Normal 0.6-0.89 Slight/Mild occlusion or Stenosis 0.41-0.59 Moderate occlusion or Stenosis <0.40 Severe occlusion or stenosis

PHYSICAL EXAMINATION Neurological Exam Sensory exam Joint position sense Vibration sense (128Hz) Light touch Two point discrimination Deep touch/Pressure Motor exam DTR-Achilles tendon Abnormal gait A reduction in the ankle jerk reflex may also be indicative of peripheral neuropathy.

PHYSICAL EXAMINATION Structural deformities: -Hammer toes -Claw toes MSS exam Structural deformities: -Hammer toes -Claw toes -Charcot deformity Small muscle atrophy Limited joint movement Prior amputation Probe to bone test muscle wasting (guttering between metatarsals) -Also called Charcot joint or neuropathic joint, Charcot arthropathy is a progressive condition of the musculoskeletal system that is characterized by joint dislocations, pathologic fractures, and debilitating deformities. This disorder results in progressive destruction of bone and soft tissues at weight-bearing joints; in its most severe form, it may cause significant disruption of the bony architecture. Charcot arthropathy can occur at any joint; however, it occurs most commonly in the lower extremity, at the foot and ankle.

Probe to bone test probing to the bone. A sterile metal probe is inserted into the ulcer if it penetrates to the bone it almost confirms the diagnosis of osteomyelitis. Chronic discharging sinus and sausage-like appearance of the toe are the clinical markers of osteomyelitis. Definitive diagnosis requires obtaining a bone biopsy for microbial culture and histopathology.

Harris Mat -One of the best and simple tool to measure the plantar pressure. • Measures patient weight disbursement  -helps to easily identify potential points of ulceration for diabetic individuals. 

FOOT DEFORMITIES It is crucial to identify the presence of Charcot neuroarthropathy as this is likely to go unnoticed by the patient until a grossly deformed insensitive foot results, which is at an increased risk of ulceration (Figure 1). During the acute stage, the affected foot is swollen with pain or discomfort. On examination, the foot is warm, with a temperature differential of >2°C in comparison to the contralateral foot and may appear inflamed and swollen. The temperature of the overlying skin can be measured with an infrared thermometer and may be helpful in monitoring the disease activity of an acute Charcot foot.30 Acute Charcot foot may be misdiagnosed as cellulitis, osteomyelitis, inflammatory arhropathy or deep vein thrombosis.31 Therefore, a high index of suspicion is necessary so as to allow early identification and appropriate treatment of the acute Charcot foot. Once the acute phase of Charcot's subsides, which may take several months; the foot enters a chronic stage. The chronic Charcot foot is painless and deformed, without a temperature differential. The mid-foot is commonly involved in Charcot's neuroarthropathy and can result in mid-foot collapse with a plantar bony prominence and rocker bottom foot. This is associated with a significantly increased risk of ulceration.1

DMFS GRADING SYSTEMS Aims Facilitate appropriate Rx Monitor response to Rx Prognosis Serves as form of communication

DMFS GRADING/SCORING SYSTEMS Wagner IWGDF (PEDIS) and IDSA. S(AD)/SAD University of Texas (UT) ulcer classification SINBAD ulcer classification Ulcer Severity Index (USS) Diabetic Ulcer Severity Score (DUSS) and MAID DFI Wound Score IWGDF (PEDIS) and IDSA. -clear definitions -relatively small number of categories, -more user-friendly -the IDSA classification has been prospectively validated as predicting the need for and for limb amputation Wagner -the first, and still among the most widely used, classification schemes -assesses ulcer depth and the presence of infection and gangrene -The system only deals explicitly with infections of all types (deep wound abscess, joint sepsis, or osteomyelitis) in grade 3.

WAGNER GRADING OF DMFS

WAGNER GRADING

DMFS GRADING/SCORING SYSTEMS

PEDIS classification system. Grade Perfussion Extent Depth Infection Sensation Score 1 No PAD Skin Intact Skin intact None No Loss 2 PAD, No CLI <1cm2 Superficial Surface Loss 3 CLI 1-3cm2 Fascia, muscle, tendon Abscess, Fascitis, Septic athritis 4 >3cm2 Bone or joint SIRS

DIFFERENTIAL DIAGNOSIS Tuberculous ulcer Syphilitic ulcer Sickle cell ulcer Marjolins ulcer Madura foot Cutaneous leishmaniasis

SUMMARY/CONCLUSION Clinical presentation and grading of DMFS Identifying these features of great value in prevention and management of DMFS

REFERENCES Lipsky BA, Berendt AR, Cornia PB, Pile JC, Edgar Peters E, Armstrong DG. 2012 Infectious Diseases Society of America Clinical Practice Guideline for the Diagnosis and Treatment of Diabetic Foot Infections. 2012;54(12):132–173. Bakker K, Apelqvist J, Lipsky BA, Van Netten JJ, Schaper NC, the International Working Group on the Diabetic Foot (IWGDF). Prevention and management of foot problems in diabetes: a Summary Guidance for daily practice 2015, based on the IWGDF Guidance documents. http://www.iwgdf.org/files/2015/website_summary.pdf