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Diabetic foot problems tend to be much more critical mostly as a result of three major factors: altered circulation, neuropathy and a decrease in the muscle strength. Therefore the diabetic population in general tend to have much more complications than the non-diabetic population, especially when it comes to specific foot-related entities. Once these complications occur, unfortunately the complications become very very devastating, as these statistics indicate. Proper evaluation and treatment of these diabetic patients is the first step in the management of this ever-increasing population foot ulcers, diabetic, diabetes.
Probably one of the most important initial assessments is the clinical vascular examination. There are many vascular tests that can be performed, both in the outpatient and hospital setting. Both invasively and non-invasively which will get very sophisticated tests of the vasculature of the lower limb. These tests however can be performed either at bedside or in the privacy of your own
Diabetes predisposes the patient to a number of significant foot deformities, including hammertoes, bunions, corns, calluses, ulcerations and the dreaded Charcot joint disease. There are basically two factors that contribute to the formation of hammertoes and bunions in the diabetic patient. First of all, with the presence of diabetic neuropathy, their occurs a wasting or weakening of the intrinsic muscles of the foot. These are the muscles that act to stabilize the digits and as the neuropathy progresses the digits will tend to contract and develop the hammertoe deformity. Secondly, as the neuropathy progresses, the patient lacks the ability for normal proprioception and as such they will begin to claw and grip the ground with their toes to assist with propulsion. The more they do this the tighter the tendons become and inevitably the hammertoe deformities occur. As a
Finally, a grade IV ulceration, which again indicates the presence of significant vascular compromise and small vessel disease. Ischemic ulcerations are usually distal on the foot and usually follow an end-artery pattern. In the neuropathic patient these are perfectly asymptomatic, but in a person with normal sensation these are very very painful. Again, the main question when dealing with a grade IV ulceration is, "can it heal?" This too takes into account numerous items. The patient’s activity level, the general health status of the patient, the nutritional level. It’s not just one factor to determine whether or not it is going to heal. But most important of all is the vascularity of the patient. If the supply lines aren’t open, this ulcer is just not going to heal.
The dreaded grade V gangrene of the foot. Obviously this indicates severe peripheral vascular disease. The question here is not so much about healing the foot as it is determining the accurate site of amputation and possible revascularization to save the limb. This is certainly considered a medical emergency.
Let’s review over the next minute or so, about these ulcers before we move on to the next topic. Is this a grade I ulceration? Certainly if you took depth alone as the only indication, you could certainly consider it a grade I. Is it a grade II ulceration? Well, if you use some gentle blunt probing you might indicate that this is a sinus tract that penetrated deeper through the dermis, and a grade II determination would be considered. Is it a grade III? Possibly. Maybe through accurate lab tests, some evidence of
The management phase occurs either weekly or biweekly, depending on the severity of the ulcer. The ulceration is debrided and a sterile dressing applied. The shoes and shoe insoles are evaluated and accommodations are made as necessary, and frequently the medical record is updated as necessary. It is typically necessary to make some kind of an accommodation to the insole of the patient’s shoe in an attempt to redistribute weight or prevent pressure occurring on the ulcerative site. In some patient’s the only way to do this is to get them totally non-weight bearing. The debridement, the evaluation, the measurements of the ulceration must be done under the strictest sterile conditions. Frequently the shoe that the patient wears into the office should not necessarily be the same shoe that they wear when they leave. If pressure is a problem then some kind of an accommodative shoe or shoe insole must be utilized to attempt to change the way they ambulate and take away the pressure. We frequently utilize the postoperative shoe with the Plastizote insole as
The reassessment phase occurs usually on a four to six week basis. This is usually done to get a repeat of the labs, take more x-rays to evaluate the patient’s progress. This is actually a much longer visit than the management and it’s very similar to the initial assessment. The ulcers are evaluated to make sure they are not becoming infected, or the circulatory status is not being affected. The grade I and II’s evaluated to make sure it is not progressing to a grade III or IV. And long term goals are evaluated and established at this visit. The taking of the x-rays is a critical part of the overall evaluation of the diabetic patient.
A healing cast or a contact cast is a very important type of dressing. We found that it is not used very frequently as a first line type of therapy at our clinic. The idea behind the contact cast is to attempt redistribute the weight evenly throughout the entire sole of the foot in an attempt to promote the healing process. The walking braces or walking cast may be utilized as another attempt at a dressing to alleviate pressure. Oftentimes the inside of the cast can be modified with material to redistribute weight in such a way as to take pressure off an involved area. We may frequently utilize this type of a cast in a patient where compliance is a problem.
The ulceration on the right indicates clinical healing. The whole idea here is that if you are going to be able to predict continued healing of a ulceration you must be able to observe it every single time it is evaluated. This is regardless of the initial grade that the ulcer is at presentation.
Finally, maintenance. This occurs every four to six weeks. This is basically a long term approach to be assured that the ulcer is not occurring. This is done by educating the patient and general monitoring of the patient through the use of shoe therapy and
Probably the most devastating deformity of the diabetic foot is the diabetic Charcot joint that we see here. This is basically the result of fracture, effusion and ligamentous laxity. This is followed by erosion of the articular cartilage, fragmentation, luxation, disintegration and finally collapse of the entire foot. This may be the result of one specific injury but more commonly it is the result of moderate stress to the bones and joints of the foot and ankle in the insensate foot. The differentiation of Charcot joint disease from deep infection is actually very difficult, both clinically and radiographically. The treatment of choice is still, at this point, deep bone biopsy to differentiate the Charcot joint disease from osteomyelitis. Charcot joint disease, again, is a devastating condition affecting both the foot and the leg, which may necessitate the amputation as a result of lack of coordination for function and