Makindo Medical Notes

Related Subjects: Type 1 DM |Type 2 DM |Diabetes in Pregnancy |HbA1c |Diabetic Ketoacidosis (DKA) Adults |Hyperglycaemic Hyperosmolar State (HHS) |Diabetic Nephropathy |Diabetic Retinopathy |Diabetic Neuropathy |Diabetic Amyotrophy |Maturity Onset Diabetes of the Young (MODY)

Diabetes: Complications

Amputations are common but preventable with early intervention. Effective multidisciplinary care, including assessment for vasculopathy, neuropathy, bony deformity, and infections, can significantly improve outcomes.

About

• The traditional belief that surgery is ineffective due to microvascular disease is outdated; treatment of diabetic foot problems is highly beneficial.
• A multidisciplinary team approach involving surgeons, endocrinologists, radiologists, and microbiologists is essential for optimal care.

Etiology (Multifactorial)

• Vascular injury: Accelerated atherosclerosis leading to vessel narrowing and ischaemia.
• Tissue hyperglycemia: Provides an environment conducive to infection.
• Autonomic neuropathy: Reduced sweating leads to dry skin and poor skin integrity.
• Sensory neuropathy: Increased susceptibility to injury due to lack of protective sensation.
• Motor neuropathy: Foot deformities, such as claw foot, increase pressure points and risk of ulcers.

Clinical Presentation

• Signs of ischaemia, ulcers, and necrosis may be present.
• Cold limb with reduced pulses indicating poor blood supply.
• Neuropathic deformities like claw foot are common.

Investigations

• Blood Tests: FBC, U&E, baseline clotting, HbA1c, CK (for rhabdomyolysis).
• Imaging:
  • ECG: Look for AF or signs of recent MI.
  • CXR: Check for cardiomegaly.
  • Doppler Ultrasound: Assess leg vessel pulsations.
  • MRI: Helpful for identifying bone infection and osteomyelitis.
  • MR Angiography: Defines vascular anatomy and assists in surgical planning.

Wagner Classification for Diabetic Foot Ulcers

• Grade 0: Intact skin
• Grade 1: Superficial ulcer of skin or subcutaneous tissue
• Grade 2: Ulcers extending to tendon, bone, or joint capsule
• Grade 3: Deep ulcer with osteomyelitis or abscess
• Grade 4: Partial gangrene of foot
• Grade 5: Whole foot gangrene

The Wagner Classification predicts the 6-month risk of amputation and mortality. Suitable for inpatient evaluation of diabetic foot ulcers.

Scoring for Diabetic Foot Ulcer Assessment

Management and Preventive Care

• Routine Foot Examinations:
  • Provide diabetic foot checks annually at diagnosis and subsequently, or sooner if foot issues arise.
  • Educate patients on risk factors and daily foot care, including proper nail trimming and checking between toes.
  • Advise against tight shoes, rough seams, and recommend daily sock changes.
• Screen for Risk Factors:
  • Past history of foot ulcer, amputation, or end-stage renal disease.
  • Symptoms of peripheral neuropathy, peripheral arterial disease, or claudication.
  • Foot care habits and smoking history.
• Foot Examination:
  • Check for peripheral neuropathy using a 10g monofilament to assess for loss of protective sensation (LOPS).
  • Assess for peripheral arterial disease by palpating pedal pulses and, if indicated, check ABPI (caution: may be falsely elevated due to calcification).
  • Evaluate for ulceration:
    • Neuropathic: Often on the plantar surface or bony prominences.
    • Neuroischaemic or ischaemic: Common on toe tips or foot’s lateral border.
    • Pre-ulcerative signs include callus, oedema, or blistering.
  • Look for infection signs: Inflammation, induration, or purulent discharge.
  • Assess for deformities: Claw toes, large bony prominences, joint mobility.
• Risk Classification:
  • Low Risk: No risk factors.
  • Moderate Risk: One risk factor.
  • High Risk: Previous ulcer, amputation, or multiple risk factors.
  • Active Problem: Ulceration, infection, or suspected Charcot arthropathy.

Referral and Follow-Up

• For limb-threatening conditions: Immediate referral to acute care services.
• Non-limb-threatening problems: Urgent referral to foot protection services (within 1 working day).
• High-Risk Patients: Referral to foot protection services within 2–4 weeks; frequent follow-ups every 1–2 months.
• Moderate Risk: Foot checks every 3–6 months.
• Low Risk: Annual foot examination.

Emergency Management

• Infection Management: IV antibiotics for cellulitis (cover for Staph, Strep, anaerobes) and surgical consult for deep infections.
• Charcot Arthropathy: Urgent surgical review for deformity, inflammation, or abnormal loading.
• Foot Hygiene: Address poor nail care, fungal infections, and unclean socks.