Metabolic control

It is important to make sure that there are no systemic, metabolic or nutritional disturbances to impair the response to infection and retard healing of wounds. In severe infections, considerable metabolic decompensation may occur. Full resuscitation is urgently required with intravenous fluids and intravenous insulin sliding scale which is often necessary to achieve good blood glucose control whilst the patient is infected. This is followed by a basal-bolus regimen of three times a day...

Moulded insoles

These are mainly used to prevent recurrence of ulcers. They are designed to redistribute weightbearing away from vulnerable pressure areas and at the same time provide a Fig. 4.9 Cradled insole with excavated sink filled with Neoprene over the mid-foot to accommodate plantar deformity. suitable cushioning and total contact with the sole. These insoles may occupy too much space for them to be accommodated in anything but bespoke shoes, although an extra-depth stock shoe can sometimes accommodate...

Malignant ulcers

We have seen a number of cases of malignant tumours masquerading as diabetic foot ulcers. Several required more than one biopsy to confirm the diagnosis. Fig. 4.42 This subungual lesion, shown 1 week following biopsy, was a squamous cell carcinoma. 'Cauliflower' appearance and development within a scar were common factors. We have also seen amelanotic malignant melanoma masquerading as subungual ulceration and basal cell and squamous cell carcinomas which were thought to be plantar warts....

Ulcer with surrounding erythema

There will usually be local signs of infection as described above. There is a localized erythema, warmth and swelling usually associated with ulceration, although the portal of entry of infection may be a corn, callus, blister, fissure or any other skin break (Fig. 5.8). In the darkly pigmented foot, cellulitis can be difficult to detect, but careful comparison with the other foot may reveal a tawny hue. Fig. 5.8 This interdigital ulcer has associated local erythema. Fig. 5.8 This interdigital...

Eczematous eruption within cast

A 42-year-old neuropathic man with type 1 diabetes of 40 years' duration was given a total-contact cast for acute Charcot's osteoarthropathy. After 3 weeks he developed an eczematous eruption of the whole area covered by cast and some areas on the other leg and arms. He underwent patch testing by dermatologists, including testing to epoxy resins. These tests were all entirely negative, making a contact eczema rather unlikely, although it is possible that he was allergic to another component of...

Feckless patient with endstage renal failure

A 44-year-old woman with type 1 diabetes of 26 years' duration, proliferative retinopathy, profound neuropathy and end-stage renal failure treated by renal transplant had her feet checked at monthly intervals at the renal unit as part of a research protocol. Her foot pulses were palpable. She was educated in foot care, foot inspections and early reporting of any problems. However, during a 3-year period she suffered nine separate episodes of foot trauma, none of which she reported early they...

Podiatrist Diabetic Nursing Case Study

A 50-year-old man with type 1 diabetes of 30 years' duration underwent amputation of the second ray of his right foot for wet gangrene. At discharge from hospital he was reluctant to wear special shoes. After the foot healed he developed heavy callus over his 1st and 4th metatarsal heads. Speckles of blood within the callus indicated a preulcerative state (Fig. 3.6). He agreed to wear bespoke shoes after the significance of the blood within the callus was explained. The orthotists supplied...

Trauma infection necrosis and ray amputation

A 56-year-old diabetic man with type 1 diabetes of 31 years' duration and peripheral neuropathy stubbed his left hallux when walking barefoot. He was aware that the nail was damaged but felt no pain and assumed the injury was trivial. He denied ever receiving foot care education and had not attended the diabetic foot clinic. One week later he attended casualty with a necrotic hallux and cellulitis spreading up the foot (Fig. 6.13). Pedal pulses were bounding. Intravenous antibiotics were...

Wound control

Cavity foot ulcers in diabetic patients a comparative study of Cadexomer Iodine ointment and standard treatment. An economic analysis alongside a clinical trial. Acta Derm Venereol 1996 76 231-5. Armstrong DG, Lavery LA, Abu-Rumman P et al. Outcomes of subatmospheric pressure dressing therapy on wounds of the diabetic foot. Ostomy WoundManag 2002 48 64-8. Bakker DJ. Hyperbaric oxygen therapy and the diabetic foot. DiabMetab Res Rev 2000 16 (Suppl 1) S55-S58....

Classification And Staging

Neuroischemic Ulcer

After completing this basic assessment, it will now be possible to classify the diabetic foot. For practical purposes, the diabetic foot can be divided into two distinct entities the neuropathic foot and the neuroischaemic foot. Neuropathy is nearly always found in association with ischaemia, so the ischaemic foot is best called the neuroischaemic foot. In rare cases the foot may clinically be ischaemic without signs of neuropathy, but in practice, the diabetic ischaemic foot is treated in the...

Necrosis and renal impairment

Patients with advanced diabetic nephropathy or end- Fig. 6.9 A small split in dry skin on the border of the foot of a patient in end-stage renal failure treated with haemodialysis is becoming necrotic. Fig. 6.9 A small split in dry skin on the border of the foot of a patient in end-stage renal failure treated with haemodialysis is becoming necrotic. stage renal failure have an increased propensity to develop necrosis. Most have anaemia, neuropathy (which may be aggravated by uraemia) and...

Blue discolouration in a neuroischaemic foot

A 48-year-old man with type 1 diabetes mellitus of 20 years' duration, peripheral neuropathy, background retinopathy and no proteinuria presented with a 1-week history of malaise, high blood glucose and a 2-day history of discomfort and redness of the right foot. There was no history of trauma. There was an area of erythema over the dorsum and both medial and lateral aspects of the right foot, which was also oedematous. There was no break in the skin (Fig. 5.20a). Body temperature was 39.2 C,...

Delayed presentation of infection masked by callus

A 72-year-old woman with type 2 diabetes of 20 years' duration and peripheral neuropathy developed 'a dark spot' on the apex of her right 3rd toe and applied sterile gauze which was replaced at weekly intervals. The toe did not improve and regular dressings were continued for several months until her daughter noticed that the toe had become pink, and brought her up to the diabetic foot clinic. Her pedal pulses were strong and bounding. A plaque of callus covered the entire apex of the pink toe...

Large tissue deficit in a neuroischaemic foot secondary to infection needing distal arterial bypass

Diabetic Heel Ulcers Pictures

A 43-year-old male with type 1 diabetes of 27 years' dura tion, with peripheral and autonomic neuropathy, was referred with indolent neuropathic ulceration complicated by local cellulitis over the left 5th metatarsal head His pedal pulses were palpable. He was treated with ora amoxicillin 500 mg tds and fludoxacillin 500 mg qds anc outpatient debridement. His deep wound swab hac grown Staphylococcus aureus and Streptococcus group G. The cellulitis resolved and he was given a total-contact cast....

Bleeding after debridement

An 89-year-old man with type 2 diabetes of 29 years' duration was taking warfarin. He had dry necrosis of the apex of his right hallux and regularly underwent gentle debridement in the diabetic foot clinic. On one occasion, on the day following debridement, his family noticed that blood was seeping through the dressings on his hallux. Despite rest and elevation the foot continued to bleed and the patient attended casualty. The bleeding was staunched by applying a calcium alginate dressing with...

Wound healing criteria for amputation surgery

Measurements of TcPo2 are useful to predict accurately the presence of critical vascular disease and the success of major or minor amputations. TcPo2 levels > 30 mmHg, bode well for healing of a forefoot amputation, and are more accurate predictors than a palpable pedal pulse. TcPo2 levels < 30 mmHg indicate significant vascular disease and foreshadow wound healing failure and amputation. These patients require well-timed vascular surgery consultation, arteriography and revascularization....

Fear of gangrene

Some patients and their families find necrotic feet deeply upsetting. The use of the word 'gangrene' can distress and frighten some patients. It should be explained that just because a small area of the foot has developed necrosis it does not mean that the whole foot will be destroyed or that amputation is inevitable. The health-care practitioner should never express distaste or disgust. If he does not know the patient well, then before the foot is uncovered he should ask whether the patient...

Lesser metatarsal osteotomy

Modifizierter Penis

Dorsiflectory metatarsal osteotomies are performed for the treatment of lesser metatarsalgia, most often for Fig. 8.14 Chronic intractable plantar keratosis beneath the 2nd metatarsal head. The callus has been debrided, revealing preulcerative haemorrhage within the skin. This is an indication for lesser metatarsal osteotomy. Fig. 8.13 Sesamoidectomy. (a) Intraoperative photograph, the ulcer has been excised, (b) The hypertrophic tibial (medial) sesamoid has been grasped with a bone clamp and...

Crutches

Young and active patients with neuropathic ulcers may do well with crutches as an adjunct to other pressure-relieving techniques. However, patients with impaired joint position sense or postural hypotension may be unsteady on crutches. Many patients with diabetes of long standing, especially the elderly, do very poorly with crutches and are prone to falls. It is important to check for Romberg's sign, before dispensing crutches. When asked to stand with a narrow base of support and then to close...

Foreign body in foot

A 68-year-old woman with insulin-treated type 2 diabetes of 20 years' duration complained of pain on the back of the left heel and a superficial ulcer surrounded by a halo of erythema Fig. 4.34a . She was unaware of the cause of the ulcer. An X-ray showed two dipped-off insulin needles in the soft tissues of her heel Fig. 4.34b . She had previously Fig. 4.34 a The superficial ulcer of unknown aetiology surrounded by a halo of erythema, b X-ray reveals two clipped-off insulin needles embedded in...

Case Study

A 26-year-old man with type 1 diabetes of 20 years' duration had acute onychocryptosis Fig. 2.6a which had not Fig. 2.5 a Onychocryptosis a spike of nail has been left behind after cutting, and b the offending spike has been removed and lies on the nail plate. Fig. 2.5 a Onychocryptosis a spike of nail has been left behind after cutting, and b the offending spike has been removed and lies on the nail plate. responded to palliative care and underwent total nail avulsion. His toe healed in 5...

Necrosis from Pseudomonas infection

A 77-year-old man with type 2 diabetes of 12 years' duration developed ulceration on the lateral aspect of his right 5th metatarsal head. His feet were neuroischaemic. There was a sudden deterioration with a mild fever and spreading wet necrosis Fig. 6.5a . A tissue sample was taken for culture which revealed a pure heavy growth of Pseudomonas. The patient was treated with antipseu-domonal therapy in the form of ceftazidime 1 g tds and the necrosis which had previously been wet became dry and...

Transmetatarsal amputation with excision of plantar ulcer

Chronic non-healing neuropathic plantar ulceration is often associated with the complications of soft tissue infection and osteomyelitis. Cases which are refractory to conservative care may benefit from a modified transmetatarsal amputation with excision of a triangular wedge of skin from the plantar flap. I have also employed this technique, in the absence of a plantar ulcer, to remodel excessively broad plantar flaps, thereby avoiding redundant skin and unsightly dog-ears. Following a...

Autoamputation of a neuroischaemic necrotic digit

Aotoamputation

A 65-year-old man with type 2 diabetes of 12 years' duration was referred to the diabetic foot clinic with a dry necrotic 4th toe Fig. 6.25a . He was admitted for vascular assessment but no intervention was possible so the necrosis was treated conservatively in the belief that surgical removal would leave a large defect which would be difficult to heal in an ischaemic foot. His transcutaneous oxygen tension was 25 mmHg. He was given oral antibiotics, regular debridement along the demarcation...

Achilles tendon lengthening

Armstrong DG, Stacpoole-Shea S, Nguyen H, Harkless LB. Lengthening of the Achilles tendon in diabetic patients who are at risk for ulceration of the foot. J Bone Joint Surg 1999 Apr 81A 4 535. Grant WP, Sullivan R, Sonenshine DE et al. Electron microscopic investigation of the effects of diabetes mellitus on the Achilles tendon. Foot Ankle Surg 1997 Jul-Aug 36 4 272-8. Hatt RN, Lamphier TA. Triple hemisection a simplified procedure for lengthening the Achilles tendon. N Engl Med 1947 236 166-9....

Delay in presentation due to confusion between blood blister and wet necrosis

A 67-year-old man with type 2 diabetes which had not previously been diagnosed, developed what he took to be a blood blister on his left hallux. The lesion was not painful, he felt well, and he did not seek treatment until he noticed an unpleasant odour and went to casualty. The toe was infected and necrotic. Pedal pulses were bounding. His vibration perception threshold was 45 volts Fig. 6.3 . He underwent amputation of the hallux and the foot healed in 4 months. Three weeks after he was...

Rigid hammer toe deformity

A 64-year-old man, a retired pilot, with type 2 diabetes of 16 years' duration, was followed regularly in the diabetic foot clinic for treatment of a rigid hammer toe deformity of his right 2nd toe, with recurrent ulceration over the proximal interphalangeal joint. The patient underwent an elective proximal interphalangeal joint arthroplasty, with lengthening of the extensor hallucis longus tendon and dorsal capsulotomy of the metatarsophalangeal joint. A Kirschner wire was not used in this...

Lisfranc amputation

A 50-year-old man with a history of IV drug abuse and type 2 diabetes underwent amputation of his right 2nd toe and was referred to us for surgical management of his infected right foot. Examination revealed several draining ulcers and sinus tracts, extending from the site of his amputated 2nd toe, to beneath the 2nd and 3rd metatarsal heads and into the central plantar space Fig. 8.33a . Radiographs revealed osteolytic changes in the 2nd and 3rd metatarsals consistent with osteomyelitis. The...

Mechanical control

Evidence-based options for offloading diabetic wounds. Clin Podiatr Med Surg 1998 15 95-104. Armstrong DG, Nguyen HC, Lavery LA etal. Off-loading the diabetic foot wound a randomized clinical trial. Diabetes Care 2001 24 1019-22. Baumhauer JF, Wervey R, McWilliams J etal. A comparison study of plantar foot pressure in a standardised shoe, total contact cast and prefabricated pneumatic walking brace. Foot AnkleInt 1997 18 26-33. Boninger ML, Leonard JA. Use of bivalved...

Scalling Dermatitis Diabetes

Allergic Contact Dermatitis Fot

A 50-year-old female with undiagnosed type 2 diabetes, applied Bazooker, a proprietary wart remedy, to a small brown tender papule over her right third metatarsal head. Within a few days she developed a cutaneous erosion which failed to heal for 9 months and became increasingly painful Fig. 2.13a,b . Diabetes was diagnosed by her Fig. 2.13 a Ulcer following application of a proprietary wart remedy which proved to be a squamous cell carcinoma, b Close-up of lesion. Fig. 2.13 a Ulcer following...

Fifth metatarsal head resection

Weil Osteotomy

This procedure is well suited for older sedentary individuals, and for patients with osteopenia or osteomyelitis of the metatarsal head, where a transpositional osteotomy is not appropriate. Although transfer lesions callus or ulcer have been reported to occur beneath adjacent Fig. 8.15 The Weil lesser metatarsal shortening osteotomy, a The lesser toe is plantarflexed, and the oblique osteotomy cut begins at the distal dorsal edge of the articular cartilage, b Proximal displacement of the...

Practice Points

The basic approach to the diabetic foot is assessment, classification, staging and multidisciplinary management Diabetic feet can be classified into neuropathic and neuroischaemic feet The natural history of the diabetic foot falls into six stages normal, high risk, ulcerated, infected, necrotic and unsalvageable Multidisciplinary management consists of mechanical, wound, microbiological, vascular, metabolic and educational control The multidisciplinary foot care service should include...

Classification

The simple staging system differentiates between ulcers on neuropathic feet and ulcers on ischaemic feet. The basis of this classification is the presence or absence of ischaemia in the common background of neuropathy. The majority of ischaemic feet in diabetes will also have neuropathy and therefore we describe the ischaemic foot as neuroischaemic. However, there may be some ischaemic feet with minimal or no neuropathy and the ulcers in these feet are perhaps more accurately called ischaemic....

Practical Assessment

Periungual Cellulitis Pictures

This can be divided into three parts Every attempt should be made to encourage the patient to be open and non-defensive. The history can be divided into the following sections Be aware that some patients may be asymptomatic due to neuropathy. The presenting complaint is usually one or more of the following For skin breakdown, swelling and colour change or any other presenting complaints, the following questions may be helpful As regards pain, this maybe a specific complaint alone or it may...

Advances In Diabetic Foot Care

Carola Zemlin

The diabetic foot has become a major area of interest, and insight has been gained into the reasons why diabetic feet go wrong and the ways in which patients can be helped. Of all the complications of diabetes, the diabetic foot is probably the easiest to prevent and treat. The groundswell of interest in the diabetic foot surged in the 1980s, and developments in foot care included the setting up of multidisciplinary diabetic foot clinics Fig. 6 and the pioneering educational work of Jean...

Historical Background

Motor Neuropathy Foot Structure

The last century made great inroads into improving the management of diabetes. The early work of pioneers such as Nicolas Paulesco in Rumania and Georg Zuelzer in Germany culminated in the work of Banting, Best, Collip and Macleod in Canada who produced a pancreatic extract which was used successfully in patients and ended the Fig. 6 International visitors at the King's Diabetic Foot Clinic left to right, Dr Kamenov Bulgaria , the Authors, Dr Harkless USA and Dr Plamen Bulgaria . Fig. 7 The...

Prologue

Severe Gangrene

He's both their parent and he is their grave, And gives them what he will, not what they crave. Pericles, Prince of Tyre, II, iii, William Shakespeare Fig. 1 Foot from the UK. This 85-year-old man with type 2 diabetes of 8 years' duration received regular dressings of his ulcerated ischaemic foot for 9 months, but was not referred until extensive gangrene had developed. Fig. 2 Foot from Ukraine. This 48-year-old man with type 2 diabetes of 12 years' duration trod on a nail and developed severe...

The Scope Of The Problem

Sepsis Foot Diabetic

Diabetic foot complications are a major global public health problem. Amputation rates vary throughout the world but are always increased in people with diabetes compared to those without diabetes. Amputations are increasing in diabetic patients. Throughout the world, health-care systems, both public and private, have been unsuccessful in managing the overwhelming problems of patients suffering with diabetic foot complications. The results of this failure are shown in the following case...