What is happening and how to treat it Helen Moakes Specialist Diabetes Podiatrist

National Guidelines and Statistics Diabetes annual foot review – the foot assessment How do problems start?

Types of diabetic foot Acute foot problems Charcot foot What to do with them!

     NICE CG10 – Prevention and Management of Foot Problems in Type 2 Diabetes NICE CG119 – Inpatient Management of Diabetic Foot Problems Putting Feet First – NHS Diabetes National Minimum Skills Framework for Commissioning of Foot Care Services for People with Diabetes NSF Diabetes – DoH document

     1 in 7 people with diabetes will develop a foot ulcer 1 in 12 ulcers results in an amputation 8-10% of inpatients have a pressure sore and 50% of these have diabetes 25% of diabetic patients are admitted to hospital with foot ulceration as primary diagnosis Direct relationship between the time to healing and the time to assessment

   70 amputations per week, of which 80% are potentially preventable In 2007/2008 nearly a quarter (23 per cent) of people did not have a foot check Diabetes complications of the foot estimated to account for 20% of total cost of diabetes care in UK

    On newly diagnosed patients and annually thereafter Identifies risk factors (neuropathy, ischaemia, deformity, previous ulceration, smoking, poor glucose control, callosities) Assessment will result in a Risk Classification or Status – QOF indicator DM29 Risk classification informs education needs and further care planning

What to check?

-

Foot pulses

(Dorsalis Pedis & Posterior Tibial) Check by hand Doppler if unable to palpate Oedema Also an indicator of vascular problems elsewhere

 What to check?

   

Protective pain sensation

(neuropathy) - 10g Monofilament (Bailey/Owen Mumford) - Test sites - Tell patient result!

 Diagnosis of neuropathy means greatly increased chance of developing foot ulcer due to inability to sense pain

        When undertaking the diabetes foot assessment, look at: Foot shape Deformity Footwear Smoking Glucose control Callosities Risk status – NICE guidelines and QOF

      

Low Risk

- Normal sensation, palpable pulses

Increased Risk or At Risk

- Neuropathy OR absent pulses

High Risk

- Neuropathy AND/OR absent pulses AND pathology

Ulcerated foot

    High blood glucose levels Start of damage to nerves and blood vessels Diabetes may not be diagnosed Once diagnosed, poor control of BG levels        Lack of education and knowledge Fear Injury/trauma Painless!

Ischaemia - pain Painful neuropathy Amputations



Neuropathic

      Pink and warm Good pulses Abnormal monofilament result Dry Callus High arch, claw toes 

Neuro-ischaemic

     Dusky/Blueish and cool/cold Non-palpable pulses Abnormal monofilament (?) Little callus, glassy Pain

        Common Look ‘normal’ Education of paramount importance Protection – footwear, insoles, not barefoot!

Podiatry care if required – varies with area BG control Painful neuropathy Swift referral

        Less common Fragile Life expectancy reduced Often painful Poor healing Protection essential to prevent injury/trauma Podiatry care Swift referral

Don’t leave it!

Find out your nearest hospital Foot Clinic contact details

     Assess urgency (pyrexic, BG level, wound) Get a history Will almost always require referral to Foot Clinic Often requires admission If unsure, get advice

     Blisters Callus with tissue breakdown underneath Ingrowing toenail Accidental trauma – stubbing toe, cuts/grazes

ANYTHING INFECTED

    Process affecting the bony structure of the feet Rare but under diagnosed Affects neuropaths with good blood supply Diagnosis difficult – differentials?

     Neuropathic – insensate Bones within foot/ankle soften due to arterio-venous shunting Bounding foot pulses TRAUMA ??

Bones begin to fracture within foot/ankle     Foot may swell, redden, increased temperature Mostly unilateral, 20% bilateral involvement Pain/discomfort??

Foot/ankle changes shape (collapse/rocker bottom)

...but we can avoid this...

     REFER TO FOOT CLINIC X-ray – not as useful in early stages but gives a baseline Bone scan – detects heat HbA1c, Hb, ESR & CRP Rule out infection, DVT, etc

    TOTAL CONTACT PLASTER CAST – gold standard Time in cast varies – couple of months to 18 months Transition to Aircast, then custom footwear Can take 3 years  Prevent by good BG control, lessen complications, education

 If in doubt with any diabetic foot problem...

SEEK ADVICE.......FAST!

   Hospital MDT foot clinics are there to help Diabetic feet can deteriorate fast, especially with infection Prevention is key

Any Questions?