Diabetes: Foot Problems
ℹ️ About
- 👣 Amputations are common but preventable with early recognition and intervention.
- 🩺 The old belief that microvascular disease made surgery futile is outdated - active management is highly beneficial.
- 🤝 A multidisciplinary approach (surgeons, endocrinologists, radiologists, microbiologists, podiatrists) is key for optimal outcomes.
Etiology (Multifactorial)
- 🩸 Vascular injury: Accelerated atherosclerosis → ischaemia.
- 🍬 Tissue hyperglycemia: Favors infection.
- ⚡ Autonomic neuropathy: ↓ sweating → dry skin → fissures.
- 🦶 Sensory neuropathy: Loss of protective sensation → unnoticed trauma.
- 🦴 Motor neuropathy: Deformities (e.g., claw toes) → high pressure points → ulcers.
🩺 Clinical Features
- Signs of ischaemia: 🔵 cold limb, weak or absent pulses.
- Ulceration or necrosis, often on pressure points.
- Neuropathic deformities (e.g., claw foot, Charcot changes).
🔎 Investigations
- Bloods: 🧪 FBC, U&E, LFTs, clotting, HbA1c, CK.
- Imaging:
- 📈 ECG (look for AF / recent MI).
- 🫁 CXR (cardiomegaly, heart failure).
- 🩻 Doppler (peripheral flow), MRI (osteomyelitis), MR angiography (surgical planning).
Wagner Classification for Diabetic Foot Ulcers
- 0️⃣ Intact skin
- 1️⃣ Superficial ulcer
- 2️⃣ Ulcer → tendon, bone, or joint capsule
- 3️⃣ Deep ulcer + osteomyelitis/abscess
- 4️⃣ Partial gangrene of foot
- 5️⃣ Whole foot gangrene
🔑 Predicts 6-month risk of amputation & mortality.
Diabetic Foot Ulcer Scoring
| Grade | Perfusion | Extent | Depth | Infection | Sensation | Score |
|---|
| 1 | No PAD | Skin intact | Skin intact | None | Normal | 0 |
| 2 | PAD, no CLI | <1 cm² | Superficial | Surface | Loss | 1 |
| 3 | Critical ischaemia | 1–3 cm² | Fascia/muscle/tendon | Abscess, fasciitis, septic arthritis | - | 2 |
| 4 | - | >3 cm² | Bone/joint | SIRS | - | 3 |
Management & Preventive Care
- 👣 Routine Foot Checks: Annual (or more often if problems). Teach self-care, daily inspection, avoid tight shoes/rough seams.
- 🩺 Risk Factor Screening: Past ulcer/amputation, ESRD, neuropathy, PAD, smoking.
- 🔍 Examination:
- Monofilament (10g) for neuropathy.
- Pulses + ABPI (note: may be falsely high with calcification).
- Identify ulcer type: neuropathic (plantar), neuroischaemic (toe tips/lateral border).
- Look for infection (inflammation, pus), deformities (claw toes, Charcot).
- 🟢 Risk Stratification:
- Low = no risk factors → yearly review.
- Moderate = one factor → 3–6 monthly.
- High = multiple/prior ulcer/amputation → 1–2 monthly.
- Active = ulcer/infection/Charcot → urgent referral.
Referral & Follow-Up
- 🚑 Limb-threatening: immediate acute care referral.
- ⚠️ Urgent: Foot protection team within 1 working day.
- 👣 Moderate/high risk: Specialist foot service within 2–4 weeks.
Emergency Management
- 💊 Infection: IV broad-spectrum antibiotics (Staph/Strep/anaerobes), surgical consult for deep infection/abscess.
- 🦴 Charcot arthropathy: Urgent immobilisation + surgical review.
- 🧼 Foot hygiene: Address nails, tinea, poor footwear, socks.
