Prevention Of Foot Ulcers

Based on the results of clinical examination, and or laboratory testing and imaging studies, every patient with diabetes may be classified on the basis of the risk for foot problems (Table 2.5). This classification helps as a guide for patient management. Patients with active foot ulcers are not included in this classification. Inappropriate footwear is a major cause of ulceration. The aim of providing special shoes and insoles (preventive foot wear) to diabetic patients at risk for foot...

Onychomycosis Hallux Valgus And Hammer Toe Deformity

A 68-year-old female patient with diabetes diagnosed at the age of 50 years and treated with insulin, was referred to the outpatient diabetic foot clinic because of foot deformities and recurrent superficial toe ulcers. The patient had findings of peripheral neuropathy. Peripheral pulses were palpable. No other diabetic complications were present. Onychomycosis was noticed and confirmed by direct microscopic examination of nail specimens. The skin on her feet was dry hallux valgus and hammer...

Osteomyelitis Of The First Metatarsal Head

A 74-year-old male patient with type 2 diabetes attended the outpatient diabetic foot clinic because of a chronic painless ulcer on the medial aspect of the right first metatarsal head (Figure 8.32). The ulcer developed over a bunion deformity, and had persisted for 10 months. On examination, the peripheral pulses were palpable and the patient had severe peripheral neuropathy. He could not feel pain, light touch, vibration or 5.07 monofilaments. The vibration perception threshold was above 50 V...

Convex Triangular Foot Hallux Valgus And Quintus Varus

Foot Varus

A 48-year-old female diabetic patient with type 2 diabetes diagnosed 6 months before her first visit, and treated with sulfonylurea, was referred to the outpatient diabetic foot clinic because of an ulcer on her right foot. The diabetes had been adequately controlled but the patient was already exhibiting signs of diabetic complications, such as background retinopathy and neuropathy. On examination, she had a right convex triangular foot, with an ulcer under the head of the fifth metatarsal...

Pes Cavus

A 64-year-old female patient with type 2 diabetes diagnosed at the age of 62 years was referred to the outpatient diabetic foot Figure 3.3 Pes planus with bunionette. Dorsal aspect Figure 3.3 Pes planus with bunionette. Dorsal aspect clinic for foot care. She had been treated with insulin for the last 4 years. The patient had a history of hypertension. No diabetic complications were mentioned. On examination, peripheral pulses were bounding. She had severe peripheral neuropathy (no sensation of...

Dry Gangrene Of Heel

A 74-year-old female patient with longstanding type 2 diabetes was admitted to the hospital because of a stroke. She had palsy of her left arm and foot. Her hos-pitalization was complicated by aspiration pneumonia, which confined the patient to bed for 2 weeks. The patient had a history of ischemic heart disease and hypertension. Peripheral pulses were weak in both feet. On the sixth day of her hospitalization a blister with a black base developed on the posterolateral aspect of her left foot,...

Wet Gangrene And Sepsis

Wet Gangrene

A 65-year-old male patient who had type 2 diabetes since the age of 45 years and was being treated with sulfonylureas, was brought to the emergency clinic suffering from a fever. He had left paraplegia following a stroke 6 months earlier. One month before admission the toes of his left foot became gradually very painful Figure 7.5 Calf support device which provides a larger resting surface thus offloading pressure from the heel Figure 7.7 A black ischemic ulcer on the dorsum of the left second...

Neuropathic Ulcer With Osteomyelitis

Therapeutic Nursing Shoes

A 57-year-old obese male patient with type 2 diabetes diagnosed at the age of 40 years was referred to the outpatient diabetic foot clinic because of a chronic ulcer under his right foot. He was being treated with insulin and metformin with acceptable diabetes control (HBAic 7.8 ). He had a history of background retinopathy and cataract in both eyes. He reported a severe deep tissue infection 5 years earlier after a burn sustained under his right foot. At that time he was hospitalized for about...

Onychomycosis

The patient whose feet are shown in Figures 5.12-5.16 was suffering from onychomycosis and the nails and nail beds were completely destroyed by fungus as shown in Figure 8.7. Onychomycosis per se does not cause foot problems, but when it affects the proximal nail (proximal subungual onychomycosis) it may cause chronic paronychia and serve as a portal for bacteria, resulting in deep tissue infection. It often co-exists with mycosis of the web spaces and it may be superinfected by bacteria,...

Hallux Valgus Overriding Toe Claw Toes Edema

Figure Right Toe Taping

A 68-year-old female patient with type 2 diabetes diagnosed at the age of 45 years attended the outpatient diabetic foot clinic Figure 3.17 Extra-depth shoes and custom insoles for routine chiropody treatment. she was being treated with insulin. The patient had hypertension, advanced background retinopathy which had been treated with laser in both eyes, and diabetic nephropa-thy (urine protein 2.6 g 24 h). On examination, she had severe diabetic neuropathy and gross ankle edema due to...

Pes Planus Flat Foot

A 73-year-old female patient with type 2 diabetes diagnosed at the age of 55 years and treated with insulin since the age of 65 years, attended the diabetic foot clinic because of a small superficial painful ulcer over her medial malleolus. The patient complained of dysesthesias (she had a cold or warm sensation in her feet), and she had hypertension for which she had been treated with enalapril since the age of 55 years. The ulcer was noticed 4 weeks previously and had been caused by an...

Bibliography

The International Working Group on the Diabetic Foot. International Consensus on the Diabetic Foot. Amsterdam, The Netherlands, 1999. 2. Boulton AJM, Greis FA, Jervell JA. Guidelines for the diagnosis and outpatient management of diabetic peripheral neuropathy. DiabetMed 1998 15 508-514. 3. Boulton AJM. The pathway to ulceration Aetiopathogenesis. In Boulton AJM, Connor H, Cavanagh PR (Eds), The Foot in Diabetes (3rd edn). Chichester Wiley, 2000 61-72. 4. Veves A, Uccioli L, Manes C, Van Acker...

Bone Scintigraphy Imaging

Pie Diabetico Genes

The scintigraphy findings of a patient with possible osteomyelitis are discussed below and the history of this patient is illustrated in Figures 9.3 to 9.5 in Chapter 9. A plain radiograph showed findings compatible with osteomyelitis or neuro-osteoarthropathy of the second and third Figure 8.34 Full-thickness chronic neuropathic ulcer with gross callus formation under the right fifth metatarsal head Figure 8.34 Full-thickness chronic neuropathic ulcer with gross callus formation under the...

Prominent Metatarsal Heads And Claw Toes

A 65-year-old male patient with longstanding type 2 diabetes attended the outpatient diabetic foot clinic for callus removal and treatment of ulcers on the tip of his second and fifth right toes Figure 3.27 . On examination, he had bounding pedal pulses, and severe peripheral neuropathy. Metatarsal heads were prominent, and claw toes were present. Claw toe deformities may cause prominence of metatarsal heads with subsequent Figure 3.27 Prominent metatarsal heads and claw toes callus formation...

Osteomyelitis Of The Heel

Fifth Metatarsal Head Fracture

A 71-year-old female patient with type 2 diabetes was admitted to the hospital Figure 8.35 Anteroposterior plain radiograph of patient of Figure 8.34. Osteomyelitis. Pseu-doarthrosis of a stress fracture of the upper third of the fifth metatarsal, bone resorption at the metatarsophalangeal joint, and osteolytic lesions at the fifth metatarsal epiphysis Figure 8.35 Anteroposterior plain radiograph of patient of Figure 8.34. Osteomyelitis. Pseu-doarthrosis of a stress fracture of the upper third...

Lavery La Armstrong Dg Classification Of Diabetic Foot

Surgical management of the diabetic foot. Br J Hosp Med 1976 16 227-232. 2. Wagner FW. The dysvascular foot a system for diagnosis and treatment. Foot Ankle 1981 2 64. 3. Lavery LA, Armstrong DG, Harkless LB. Classification of diabetic foot wounds. J Foot Ankle Surg 1996 35 528-531. 4. Armstrong DG, Lavery LA, Harkless LB. Validation of a diabetic wound classification system. Diabetes Care 1998 21 855-861. 5. Consensus development conference on diabetic foot wound care. Diabetes...

Heloma Molle

A 54-year-old male patient with type 2 diabetes diagnosed at the age of 48 years attended the outpatient diabetic foot clinic for callus removal. He had severe diabetic neuropathy loss of sensation of pain, light touch, temperature, vibration and 5.07 monofilaments , and he complained of mild pain on his left little toe. On examination, a painful corn was seen at the medial aspect of his left little toe Figure 3.13 . Corns are circular hyperkeratotic areas which may be soft or hard. They have a...

Peripheral Vascular Disease

Peripheral Venous Disease Foot

VASCULAR STATUS IN PATIENTS WITH diabetes The prevalence of peripheral vascular disease in diabetic patients is 15-30 . The Figure 1.4 Examination of vibration perception by the use of a biothesiometer Figure 1.4 Examination of vibration perception by the use of a biothesiometer disease progresses with both duration of diabetes and age. A diagnostic work-up of the peripheral extremities is based on clinical examination history of intermittent claudication, rest pain, walking distance, palpation...

Extensive Wet Gangrene Of The Foot

A 51-year-old male patient with type 1 diabetes diagnosed at the age of 25 years was admitted to the Vascular Surgery Department because of extremely painful wet gangrene on his right foot. The patient had proliferative diabetic retinopathy which had been treated with laser, significant loss of his visual acuity 3 10 in both eyes , hypertension and diabetic nephropathy. He had lived in a nursing home. His diabetes control was good HBAic 7 . The patient had complained of pain in his right foot...

Methods For Offloading Pressure On The Foot

Offloading Foot Ulcer

The mainstay in the management of an active plantar foot ulcer is the effective offloading of the ulcer area. Once an ulcer is Figure 2.12 Lower side of insole illustrated in Figure 2.11 Figure 2.12 Lower side of insole illustrated in Figure 2.11 present, it will not heal unless the mechanical load on it is removed. Among the methods used for this purpose are complete bed rest, crutch-assisted gait, wheelchair, and prosthetics. However, these methods are impractical for the majority of patients...

Fungal Infection With Multimicrobial Colonization

Diabetic Foot Infection

Superficial ulcers of 10 days' duration on the facing sides of the left first and second toe of a 70-year-old type 2 diabetic lady with diabetic neuropathy, before debridement are shown in Figures 8.8 and 8.9. Note soaking of the skin. An X-ray excluded osteomyelitis. Staphylococcus coagulase-negative, Pseudomonas aerugi-nosa and enterobacteriaceae were recovered after swab cultures in addition to Candida albicans. She was treated successfully with itraconazole for 5 weeks. The patient used a...

Phlegmon

Callus Formation

A 62-year-old male diabetic patient with type 2 diabetes diagnosed at the age of 42 years and treated with sulfonylurea, biguanide and acarbose and whose diabetes control was acceptable, visited the outpatient diabetic foot clinic due to infection of the sole of his right foot. He had hypertension and coronary heart disease treated with metoprolol and aspirin. He had no previous history of foot problems. On examination, the patient had fever, severe diabetic neuropathy, and bounding pedal...

Wet Gangrene Of The Hallux

Ischemic Rest Pain

A 72-year-old male patient with type 2 diabetes diagnosed at the age of 60 years and being treated with insulin, attended the outpatient diabetic foot clinic because of pain in his right hallux. His diabetes control was poor HBA1c 8.7 . He had hypertension and background retinopathy in both eyes. He was an ex-smoker. The patient had Figure 7.28 Wet gangrene of the right hallux and claw toe deformity. Ischemic hair, redness over toes, dystrophic nail changes can also be seen Figure 7.28 Wet...

Claw And Curly Toe Deformities

Curly Toed Feet

A 68-year-old female patient with type 2 diabetes attended the outpatient diabetes clinic for her usual follow-up. On examination, she had severe diabetic neuropathy and palpable peripheral pulses. Claw toe deformity of her left second and third toes was noticed, as well as a curly fourth toe Figure 3.8 . Subungual hemorrhage and ingrown hallux nail, and hemorrhagic calluses of the second and third toes were also present. A hammer deformity was seen on the second toe of her right foot....

Neuroischemic Ulcers At Various Sites

Diabetic Osteomyelitis Amputation

Neuro-Ischemic Ulcer with Osteomyelitis Neuro-Ischemic Ulcer on the Hallux with Osteomyelitis A 68-year-old obese male patient with type 2 diabetes diagnosed at the age of 46 years visited the outpatient diabetic foot clinic because of two chronic ulcers on his right hallux. He was treated with a combination of sulfonylurea during the day and a mixture of 20 rapid acting-80 intermediate acting insulin before dinner he also had dislipidemia which was being treated with simvastatin. On...

Infected Plantar Ulcer With Osteomyelitis

Infected Diabetic Foot Ulcer

A 50-year-old female diabetic patient with type 2 diabetes diagnosed at the age of 44 years and treated with sulfonylurea, was referred to the outpatient diabetic foot clinic because of a chronic infected ulcer on her left foot. The patient lived alone and she was being treated for depression she had good diabetes control. A minor trauma under her left foot was reported to have occurred 2 years previously. She had treated the injury with different types of gauzes and creams, but it failed to...

Chronic Neuropathic Ulcer With Osteomyelitis

Osteomyelitis Foot

A 46-year-old male patient with type 1 diabetes diagnosed at the age of 27 years was referred to the outpatient diabetes foot clinic because of a chronic ulcer under his right fifth metatarsal head. He had acceptable diabetes control HBA1c 7.7 , pro-liferative diabetic retinopathy treated with laser in both eyes, but no nephropathy. He complained of muscle cramps during the night and chronic constipation interrupted by episodes of nocturnal diarrhea. The patient had a history of painless...

Web Space Infection

Lumbrical Atrophy Foot

A 72-year-old female patient with type 2 diabetes diagnosed at the age of 61 years, was referred to the outpatient diabetic foot clinic because of an infection in her left foot. The patient had poor diabetes control HBAic 8.5 , and was being treated with insulin twice daily. She had background Figure 8.4 Objects collected from patients' shoes. Loss of protective sensation prevents patients from feeling injurious stimuli Figure 8.4 Objects collected from patients' shoes. Loss of protective...

Osteomyelitis Of The Hallux

Distal Phalanx Right Hallux

A 30-year-old male patient with type 1 diabetes diagnosed at the age of 11 years was admitted because of infected foot ulcers on his right hallux. He had a mild fever and a history of proliferative diabetic retinopa-thy and microalbuminuria. Diabetes control was poor HBA1c 9.5 . He reported a trauma to his left foot 2 months earlier when an object fell on his feet while working. A superficial ulcer had developed on the dorsal aspect of his right great toe the ulcer had become infected because...

Hammer Toe Stint Or Stent

Hammer Toe Stint Stent

A mallet toe consists of plantar flexion of the distal interphalangeal, and neutral position of metatarsophalangeal and proximal interphalangeal joints Figure 3.26 . Toe deformities hammer, claw, curly, mallet toe and overriding of toes are unknown in non-shoe wearing populations. Their incidence varies from 2 to 20 , and increases with age. Women are affected four to five times more often than men. Most people have no underlying disease, although neuromuscular diseases and inflammatory...

Classification Systems

Diabetic Foot Ulcer Grading

The Meggitt-Wagner classification is the most well-known and validated system for foot ulcers, and is shown in Table 2.1. The advantages and disadvantages of this classification system are described in Table 2.2. 'The University of Texas classification system for diabetic foot wounds', Table 2.1 Meggitt-Wagner classification of foot ulcers Table 2.1 Meggitt-Wagner classification of foot ulcers Table 2.2 Advantages and disadvantages of the Meggitt-Wagner classification system It is simple to...

Neuropathic Ulcer

Diabetic Heel Ulcer

Figure 5.4 Neuropathic ulcer over a bony prominence in a patient with neuro-osteoarth-ropathy Figure 5.4 Neuropathic ulcer over a bony prominence in a patient with neuro-osteoarth-ropathy its base is clean, covered by healthy granulating tissue. Therapeutic footwear was prescribed extra depth shoes with an orthotic insole and a window under the ulcerated area and the patient was advised to minimize his activities. The ulcer healed in 3 months. Ulcers in patients with midfoot collapse recur very...