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| __NOTOC__ | | __NOTOC__ |
| | {| class="infobox" style="float:right;" |
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| | | [[File:Siren.gif|30px|link=Diabetic foot resident survival guide]]|| <br> || <br> |
| | | [[Diabetic foot resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']] |
| | |} |
| | '''For patient information, click [[Diabetic foot (patient information)|here]]''' |
| | {{Infobox_Disease | |
| | Name = {{PAGENAME}} | |
| | Image = extremities_dm_foot_infection.jpg| |
| | Caption = Diabetic Foot Infection: Cellulitis and gangrene. <br> <small> (Image courtesy of Charlie Goldberg, M.D., UCSD School of Medicine and VA Medical Center, San Diego, CA) </small>| |
| | }} |
| | {{Diabetic foot}} |
| {{Diabetes mellitus }} | | {{Diabetes mellitus }} |
| {{CMG}}; '''Associate Editor(s)-In-Chief:''' [[Priyamvada Singh|Priyamvada Singh, M.B.B.S.]] [mailto:psingh13579@gmail.com]; {{CZ}} | | {{CMG}}; [[Afsaneh Morteza|Afsaneh Morteza, MD-MPH]] [mailto:afsaneh.morteza@gmail.com] {{AE}} {{Anahita}} {{DG}}; [[Priyamvada Singh|Priyamvada Singh, M.B.B.S.]] [mailto:psingh13579@gmail.com]; {{CZ}} |
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| ==Overview==
| | {{SK}} Diabetic feet; Diabetic ulcer; Diabetic foot infection; Diabetic foot ulcer; Diabetic foot syndrome |
| [[Type 2 diabetes]] and its complications are now considered as a growing health threat. It is the leading cause of [[blindness]], [[end stage renal disease]], [[coronary heart disease]] and foot ulceration which leads to [[amputation]]s. In general, the incidence of nontraumatic lower extremity amputations has been reported to be at least 15 times greater in those with diabetes than with any other medical illness. Among patients with diabetes, the lifetime risk of having foot ulcer is 15%. Diabetic foot ulcers dramatically worsen the physical, psychological and social quality of life <ref name="pmid12039404">{{cite journal| author=Assal JP, Mehnert H, Tritschler HJ, Sidorenko A, Keen H, Hellmut Mehnert Award Workshop Participants| title=On your feet! Workshop on the diabetic foot. | journal=J Diabetes Complications | year= 2002 | volume= 16 | issue= 2 | pages= 183-94 | pmid=12039404 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12039404 }} </ref>. 1 in every 4 patients with [[diabetes]] develops complications. The pathogenesis of diabetics foot is due to two causes i.e. neuropathy and [[vasculopathy]]. Due to [[neuropathy]] the patient loses sensation whereas, vasculopathy causes poor blood supply to the foot region. Due to both these contributing factors, even a small trauma to the feet can give rise to ulcer or gangrene and may even require amputation. Thus, foot examination by a podiatrist or a doctor is recommended every year.
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| == Pathophysiology== | | ==[[Diabetic foot overview|Overview]]== |
| Diabetic foot is an umbrella term for foot problems in patients with [[diabetes mellitus]]. Due to [[artery|arterial]] abnormalities and [[diabetic neuropathy]] and delayed wound healing, [[infection]] or [[gangrene]] of the foot is relatively common. The key components of diabetic foot are [[neuropathy]], [[angiopathy]] and [[trauma]] <ref name="pmid12039404">{{cite journal| author=Assal JP, Mehnert H, Tritschler HJ, Sidorenko A, Keen H, Hellmut Mehnert Award Workshop Participants| title=On your feet! Workshop on the diabetic foot. | journal=J Diabetes Complications | year= 2002 | volume= 16 | issue= 2 | pages= 183-94 | pmid=12039404 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12039404 }} </ref>. | |
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| ===Neuropathy=== | | ==[[Diabetic foot historical perspective|Historical Perspective]]== |
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| The most important cause of diabetic foot is [[neuropathy]]. This is present to some extent in more than half of the patients with diabetes older than 60 years old. Peripheral neuropathy usually is profound at the point where it leads to the formation of a foot ulcer. What causes neuropathy and why it occurs is not fully known. It is most likely caused by a combination of factors such as; high blood glucose, [[reactive oxygen species]], vasculopathy, reduced oxygenation of the nerves, [[inflammation]], [[autoimmunity]] in diabetes, [[genetic]] factors, mechanical injury, [[smoking]] and [[alcohol abuse]].
| | ==[[Diabetic foot classification|Classification]]== |
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| Generalized symmetric distal polyneuropathy is the most common and widely recognized form of diabetic neuropathy leading to diabetic foot ulcer. It may be either sensory or motor, and involves small fibers, large fibers or both. The clinical manifestations are divided into the three types of sensory, motor and autonomic neuropathy. Motor neuropathy causes wasting of small muscles of the feet with hammer toes and weakness of hands and feet.
| | ==[[Diabetic foot pathophysiology|Pathophysiology]]== |
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| Sensory neuropathy causes:
| | ==[[Diabetic foot causes|Causes]]== |
| *Impaired [[vibration]] perception and position sense
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| *Depressed tendon reflexes
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| *Dull, crushing or cramp-like pain in the bones of the feet,
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| *Sensory [[ataxia]]
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| *Shortening of the [[achilles tendon]]
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| *Abnormal thresholds for warm thermal perception
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| *Decreased neurovascular function
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| | ==[[Differentiating Diabetic foot from other diseases|Differentiating Diabetic foot from other Diseases]]== |
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| Autonomic neuropathy is the increased or decreased blood flow to the foot (hot foot) with an increased risk of [[charcot neuroarthropathy]], decreased sweating, dry skin, impaired vasomotion and blood flow. These lead to cold feet which ultimately result into the loss of skin integrity, providing a vulnerable site for infection <ref name="pmid22529027">{{cite journal| author=Alexiadou K, Doupis J| title=Management of diabetic foot ulcers. | journal=Diabetes Ther | year= 2012 | volume= 3 | issue= 1 | pages= 4 | pmid=22529027 | doi=10.1007/s13300-012-0004-9 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22529027 }} </ref>.
| | ==[[Diabetic foot epidemiology and demographics|Epidemiology and Demographics]]== |
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| ===Angiopathy=== | | ==[[Diabetic foot risk factors|Risk Factors]]== |
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| Micro and macrovascular complications are the leading cause of diabetic complications. [[Atherosclerosis]] occurs due to inflammation, which leads to the accumulation of foam cells. The vascular changes which are responsible for foot problems include stiff arteries due to calcification of the smooth muscle cells in the arterial wall (mediasclerosis). It is usually discovered by an impaired ankle brachial index ([[ABI]]). The resting ABI is the ratio of the blood pressure in the lower legs to the blood pressure in the arms. The ABI is calculated by dividing the [[systolic blood pressure]] at the ankle by the systolic blood pressures in the arm. It is a non-invasive method to assess the lower extremity arterial system and to detect the presence of arterial occlusion disease. In severe cases, it leads to ischemic foot problems, which the only treatment is [[vascular surgery]]. Even in neuropathic foot ulcers, the non healing wounds are the result of impaired blood supply to the tissue. Decreasing the central blood pressure by antihypertensive drugs may be deleterious for these patients<ref name="pmid22529027">{{cite journal| author=Alexiadou K, Doupis J| title=Management of diabetic foot ulcers. | journal=Diabetes Ther | year= 2012 | volume= 3 | issue= 1 | pages= 4 | pmid=22529027 | doi=10.1007/s13300-012-0004-9 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22529027 }} </ref>. Microvascular complications cause skin damage, [[infection]] and impaired wound healing. Once a foot ulcer develops, peripheral vascular disease is the most important factor which may contribute to adverse outcomes.Vascular complications are like a positive feedback which worsen the skin and nerve damage in [[diabetes]] <ref name="pmid22623440">{{cite journal| author=Venermo M, Vikatmaa P, Terasaki H, Sugano N| title=Vascular laboratory for critical limb ischaemia. | journal=Scand J Surg | year= 2012 | volume= 101 | issue= 2 | pages= 86-93 | pmid=22623440 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22623440 }} </ref>
| | ==[[Diabetic foot screening|Screening]]== |
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| [[Image:Microcirculation image.png|500px|Neuropathy and angiopathy in the foot have a positive feedback on each other]] | | ==[[Diabetic foot natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
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| ===Trauma=== | | ==Diagnosis== |
| | [[Diabetic foot history and symptoms|History and Symptoms]] | [[Diabetic foot physical examination|Physical Examination]] | [[Diabetic foot laboratory findings|Laboratory Findings]] | [[Diabetic foot electrocardiogram|Electrocardiogram]] | [[Diabetic foot x ray|X Ray]] | [[Diabetic foot CT|CT]] | [[Diabetic foot MRI|MRI]] | [[Diabetic foot echocardiography or ultrasound|Echocardiography or Ultrasound]] | [[Diabetic foot other imaging findings|Other Imaging Findings]] | [[Diabetic foot other diagnostic studies|Other Diagnostic Studies]] |
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| Trauma is frequently the trigger of foot [[ulcer]] as repetitive trauma and pressure to the area prevent healing. Excessive plantar pressure is related to limited joint mobility and to foot deformities (Charcot foot, hammer toe). Limited joint mobility and abnormal foot biomechanisms have been associated with an increased risk of ulceration. It could also be the result of poor vision and sensory neuropathy so that the patients does not feel the pain, nor do they see the ulcer. Loss of balance can also make patients more susceptible to falls. <ref name="pmid22529027">{{cite journal| author=Alexiadou K, Doupis J| title=Management of diabetic foot ulcers. | journal=Diabetes Ther | year= 2012 | volume= 3 | issue= 1 | pages= 4 | pmid=22529027 | doi=10.1007/s13300-012-0004-9 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22529027 }} </ref>.
| | ==Treatment== |
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| ==Epidemiology and Demographics==
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| ===Incidence===
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| It has been reported that annually, about 1 to 4 percent of those with diabetes develop a foot ulcer; 10 to 15 percent of those with diabetes will have at least one foot ulcer during their lifetime<ref name="pmid17280936">{{cite journal| author=Frykberg RG, Zgonis T, Armstrong DG, Driver VR, Giurini JM, Kravitz SR et al.| title=Diabetic foot disorders. A clinical practice guideline (2006 revision). | journal=J Foot Ankle Surg | year= 2006 | volume= 45 | issue= 5 Suppl | pages= S1-66 | pmid=17280936 | doi=10.1016/S1067-2516(07)60001-5 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17280936 }} </ref>
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| ===Gender===
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| In 1987, Borch-Johnsen et al. described a male preponderance for the development of severe microvascular complications <ref name="pmid2956021">{{cite journal| author=Borch-Johnsen K, Nissen H, Salling N, Henriksen E, Kreiner S, Deckert T et al.| title=The natural history of insulin-dependent diabetes in Denmark: 2. Long-term survival--who and why. | journal=Diabet Med | year= 1987 | volume= 4 | issue= 3 | pages= 211-6 | pmid=2956021 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2956021 }} </ref>. Diabetic foot disease is not an exception to this rule. For unknown reasons , men have a higher risk of diabetic foot disease compared to women. Some possible explanations are a higher bioavailability of [[nitric oxide]] (NO) bioavailability and NO responsiveness and the protective role of [[estrogen]] in women <ref name="pmid12538427">{{cite journal| author=Gladwin MT, Schechter AN, Ognibene FP, Coles WA, Reiter CD, Schenke WH et al.| title=Divergent nitric oxide bioavailability in men and women with sickle cell disease. | journal=Circulation | year= 2003 | volume= 107 | issue= 2 | pages= 271-8 | pmid=12538427 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12538427 }} </ref>. However the beneficial effect of these factors are reversed by [[diabetes]], irrespective of menopausal status.Nevertheless men still have a higher risk for having diabetic foot disease .
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| ==Complications==
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| Patients with diabetic foot have an increased risk of all-cause mortality, especially cardiovascular disorders, compared with patients with diabetes without a history of diabetic foot ulcer.<ref name="pmid22890823">{{cite journal| author=Brownrigg JR, Davey J, Holt PJ, Davis WA, Thompson MM, Ray KK et al.| title=The association of ulceration of the foot with cardiovascular and all-cause mortality in patients with diabetes: a meta-analysis. | journal=Diabetologia | year= 2012 | volume= 55 | issue= 11 | pages= 2906-12 | pmid=22890823 | doi=10.1007/s00125-012-2673-3 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22890823 }} </ref>
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| == Diagnosis and Evaluation==
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| A complete physical examination and patient history is the first step. it include dermatologic, vascular, neurologic and bone examination.
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| ===Dermatologic Examination===
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| *Visual inspection of the skin: peeling skin, maceration, fissuring between toes
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| *Skin temperature: Should be warm at the tibia cold at distal toe .
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| *Look for deformities, charcot foot, hammer toe, and heels.
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| ===Vascular Assessment===
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| Pulses: Bilaterally, dorsalis pedis, posterior tibialis, popliteal and superficial femoral.
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| ABI measurement:
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| * Normal 1-1.3
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| * Non compressible calcified >1.3
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| * Stenosis <0.9
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| * Advanced ischemia <0.4
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| Arterial oxygen supply could also be measured by transcutaneous oxymetery
| | [[Diabetic foot comprehensive therapy|Comprehensive therapy]] | [[Diabetic foot medical therapy|Medical Therapy]] | [[Diabetic foot surgery|Surgery]] | [[Diabetic foot primary prevention|Primary Prevention]] | [[Diabetic foot secondary prevention|Secondary Prevention]] | [[Diabetic foot cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Diabetic foot future or investigational therapies|Future or Investigational Therapies]] |
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| ===Neuropathy Assessment=== | | ==Case Studies== |
| | | [[Diabetic foot case study one|Case #1]] |
| Symptoms including burning, pin, needles, at early stages
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| Using neuropathy symptoms score (NSS)<ref name="pmid12421436">{{cite journal| author=Meijer JW, Smit AJ, Sonderen EV, Groothoff JW, Eisma WH, Links TP| title=Symptom scoring systems to diagnose distal polyneuropathy in diabetes: the Diabetic Neuropathy Symptom score. | journal=Diabet Med | year= 2002 | volume= 19 | issue= 11 | pages= 962-5 | pmid=12421436 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12421436 }} </ref> and neuropathy disability score (NDS),<ref name="pmid15317601">{{cite journal| author=Daousi C, MacFarlane IA, Woodward A, Nurmikko TJ, Bundred PE, Benbow SJ| title=Chronic painful peripheral neuropathy in an urban community: a controlled comparison of people with and without diabetes. | journal=Diabet Med | year= 2004 | volume= 21 | issue= 9 | pages= 976-82 | pmid=15317601 | doi=10.1111/j.1464-5491.2004.01271.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15317601 }} </ref>. Almost half of the patients with diabetes have some level of neuropathy prior to diagnosis.
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| the physician should assess;
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| *[[Muscle strength]] and tone
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| *[[Temperature]]
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| *[[Sensation]]
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| *Light touch
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| *Filament nerve conduction studies
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| *Quantitative sensory testing and autonomic testing.
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| ==Diabetic Foot Physical Examination==
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| ===Inspection===
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| * Dilated veins
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| * Scar, Sinuses
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| * Shiny skin
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| * Hair distribution
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| * Areas of Pigmentation
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| * Areas of discolouration
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| * Varicose vein
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| * Ulcers
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| * Brittle or broken nail
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| * Fungal infection
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| ===Palpation===
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| * Temperature (increase temperature- deep vein thrombosis, decrease temperature-ischemia)
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| * Tenderness (squeeze calf muscle and achilles tendon for tenderness)
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| * Pulsation- Dorsalis pedis
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| * Capillary filling time
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| * Ulcers in pressure areas like ball of great toe, base of fifth metatarsal, posterior aspect of heel
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| ===Motor Examination===
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| * Nutrition/Bulk
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| * Tone
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| * Power
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| * Reflexes
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| ===Sensory===
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| * Vibration
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| * Joint position sense
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| ==Video: Physical Examination Diabetes==
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| {{#ev:youtube|715j6zRZHaA}}
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| ==Video: Diabetic Foot Care==
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| {{#ev:youtube|DASvmFJeYX8}}
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| ==Image: Diabetic Foot Ulcer==
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| [[Image:Diabetic foot ulcer.jpg|thumb|left|Diabetic foot ulcer]]
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| <br clear="left"/>
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| ==Treatment==
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| Foot ulcers in diabetes require multidisciplinary assessment, usually by diabetes specialists and [[surgeon]]s. Treatment consists of appropriate bandages, [[antibiotic]]s (against [[staphylococcus]], [[streptococcus]] and [[anaerobe]] strains), [[debridement]] and arterial revascularisation. It is often 500 mg to 1000 mg of [[flucloxacillin]], 1 g of [[amoxicillin]] and also [[metronidazole]] to tackle the putrid smelling bacteria. Specialists are investigating the role of [[nitric oxide]] in diabetic wound healing. Nitric oxide is a powerful vasodilator, which helps to bring nutrients to the oxygen deficient wound beds. Specialists are using forms of [[light therapy]] such as LLLT to treat diabetic ulcers.
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| ==References==
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| {{reflist|2}}
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| {{WH}} | | {{WH}} |
| {{WS}} | | {{WS}} |
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| [[Category:Disease]] | | [[Category:Emergency medicine]] |
| [[Category:Medicine]]
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| [[Category:Endocrinology]] | | [[Category:Endocrinology]] |
| [[Category:Mature chapter]]
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| [[Category:Diabetes]]
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| [[Category:Aging-associated diseases]]
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| [[Category:Medical conditions related to obesity]]
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| [[Category:Primary care]]
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| [[Category:Intensive care medicine]]
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