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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]]''' | | '''For patient information, click [[Diabetic foot (patient information)|here]]''' |
| {{Infobox_Disease | | | {{Infobox_Disease | |
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| {{Diabetic foot}} | | {{Diabetic foot}} |
| {{Diabetes mellitus }} | | {{Diabetes mellitus }} |
| {{CMG}}; [[Afsaneh Morteza|Afsaneh Morteza, MD-MPH]] [mailto:afsaneh.morteza@gmail.com] '''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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| == 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===
| | {{SK}} Diabetic feet; Diabetic ulcer; Diabetic foot infection; Diabetic foot ulcer; Diabetic foot syndrome |
| *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=== | | ==[[Diabetic foot overview|Overview]]== |
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| Pulses: Bilaterally, dorsalis pedis, posterior tibialis, popliteal and superficial femoral.
| | ==[[Diabetic foot historical perspective|Historical Perspective]]== |
| ABI measurement:
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| * Normal 1-1.3
| | ==[[Diabetic foot classification|Classification]]== |
| * 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 pathophysiology|Pathophysiology]]== |
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| ===Neuropathy Assessment=== | | ==[[Diabetic foot causes|Causes]]== |
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| Symptoms including burning, pin, needles, at early stages
| | ==[[Differentiating Diabetic foot from other diseases|Differentiating Diabetic foot from other Diseases]]== |
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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.
| | ==[[Diabetic foot epidemiology and demographics|Epidemiology and Demographics]]== |
| 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== | | ==[[Diabetic foot risk factors|Risk Factors]]== |
| ===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=== | | ==[[Diabetic foot screening|Screening]]== |
| * Vibration
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| * Joint position sense
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| ==Video: Physical Examination Diabetes== | | ==[[Diabetic foot natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
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| {{#ev:youtube|715j6zRZHaA}}
| | ==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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| ==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]] | |
| <br clear="left"/>
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| ==Treatment== | | ==Treatment== |
| 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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| ==Prevention==
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| Foot ulcers can be prevented by is by frequent physical examinations, good foot hygiene, [[diabetic sock]]s and shoes, and by avoiding injury.
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| * Foot-care education combined with increased surveillance can reduce the incidence of serious foot lesions <ref name="pmid8498761">{{cite journal |author=Litzelman D, Slemenda C, Langefeld C, Hays L, Welch M, Bild D, Ford E, Vinicor F |title=Reduction of lower extremity clinical abnormalities in patients with non-insulin-dependent diabetes mellitus. A randomized, controlled trial |journal=Ann Intern Med |volume=119 |issue=1 |pages=36-41 |year=1993 |pmid=8498761}}</ref>.
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| * Footwear; all major reviews recommend special footwear for patients with a prior ulcer or with foot deformities. One review added neuropathy as an indication for special footwear. The comparison of custom shoes versus well-chosen and well-fitted athletic shoes is not clear.
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| ====Clinical Trials====
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| ''Clinical Evidence'' reviewed the topic and concluded "Individuals with significant foot deformities should be considered for referral and assessment for customized shoes that can accommodate the altered foot anatomy. In the absence of significant deformities, high quality well fitting non-prescription footwear seems to be a reasonable option" <ref name="pmid16620415">{{cite journal |author=Hunt D |title=Foot ulcers and amputations in diabetes |journal=Clin Evid |volume= |issue= |pages=455-62 |year= |pmid=16620415 |url = http://clinicalevidence.com/ceweb/conditions/dia/0602/0602_I5.jsp | based on September 2005 search}}</ref>.
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| [[National Institute for Health and Clinical Excellence]] has reviewed the topic and concluded that for patients at "high risk of foot ulcers (neuropathy or absent pulses plus deformity or skin changes or previous ulcer" that "specialist footwear and insoles" should be provided <ref name="webNICE">{{cite web
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| | title = Scope: Management of type 2 diabetes: prevention and management of foot problems (update)
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| | work = Clinical Guidelines and Evidence Review for Type 2 Diabetes: Prevention and Management of Foot Problems
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| | publisher = National Institute for Health and Clinical Excellence
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| | date = 20 February 2003
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| | url = http://www.nice.org.uk/nicemedia/pdf/footcare_scope.pdf
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| | format = PDF
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| | accessdate = 2007-12-04
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| }}</ref>
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| A [[meta-analysis]] by the [[Cochrane Collaboration]] concluded that "there is very limited evidence of the effectiveness of therapeutic shoes" <ref name="pmid10908550">{{cite journal |author=Spencer S |title=Pressure relieving interventions for preventing and treating diabetic foot ulcers |journal=Cochrane Database Syst Rev |volume= |issue= |pages=CD002302 |year= |pmid=10908550 | doi=10.1002/14651858.CD002302}}</ref>. However, the meta-analysis was published before the major trial that is in the table below.
| | [[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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| The major [[randomized controlled trial]] of specialized footwear show no benefit in patients with a prior foot ulceration (see table below).<ref name="pmid12020336">{{cite journal| author=Reiber GE, Smith DG, Wallace C, Sullivan K, Hayes S, Vath C et al.| title=Effect of therapeutic footwear on foot reulceration in patients with diabetes: a randomized controlled trial. | journal=JAMA | year= 2002 | volume= 287 | issue= 19 | pages= 2552-8 | pmid=12020336 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12020336 }} </ref> A prior, smaller, non-randomized trial that showed benefit of custom foot wear in patients with a prior foot ulceration.<ref name=pmid8721941">{{cite journal |author=Uccioli L, Faglia E, Monticone G, Favales F, Durola L, Aldeghi A, Quarantiello A, Calia P, Menzinger G |title=Manufactured shoes in the prevention of diabetic foot ulcers |journal=Diabetes Care |volume=18 |issue=10 |pages=1376-8 |year=1995 |pmid=8721941}}</ref>. In this trial, the [[number needed to treat]] was 4 patients.
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| {| class="wikitable"
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| |+ [[Randomized controlled trial]]s of interventions to prevent complications of diabetic foot.<ref name="pmid12020336">{{cite journal| author=Reiber GE, Smith DG, Wallace C, Sullivan K, Hayes S, Vath C et al.| title=Effect of therapeutic footwear on foot reulceration in patients with diabetes: a randomized controlled trial. | journal=JAMA | year= 2002 | volume= 287 | issue= 19 | pages= 2552-8 | pmid=12020336 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12020336 }} </ref> <ref name="pmid8498761">{{cite journal| author=Litzelman DK, Slemenda CW, Langefeld CD, Hays LM, Welch MA, Bild DE et al.| title=Reduction of lower extremity clinical abnormalities in patients with non-insulin-dependent diabetes mellitus. A randomized, controlled trial. | journal=Ann Intern Med | year= 1993 | volume= 119 | issue= 1 | pages= 36-41 | pmid=8498761 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8498761 }} </ref> <ref name="pmid9472868">{{cite journal| author=McCabe CJ, Stevenson RC, Dolan AM| title=Evaluation of a diabetic foot screening and protection programme. | journal=Diabet Med | year= 1998 | volume= 15 | issue= 1 | pages= 80-4 | pmid=9472868 | doi=10.1002/(SICI)1096-9136(199801)15:1<80::AID-DIA517>3.0.CO;2-K | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9472868 }} </ref> <ref name="pmid18758747">{{cite journal| author=Lincoln NB, Radford KA, Game FL, Jeffcoate WJ| title=Education for secondary prevention of foot ulcers in people with diabetes: a randomised controlled trial. | journal=Diabetologia | year= 2008 | volume= 51 | issue= 11 | pages= 1954-61 | pmid=18758747 | doi=10.1007/s00125-008-1110-0 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18758747 }} </ref> | |
| ! rowspan="2"|Trial!!rowspan="2"| Patients!!rowspan="2"| Intervention!!rowspan="2"|Comparison !!rowspan="2"|Outcome!!colspan="2"|Results!!rowspan="2"|Comment
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| ! Intervention!!Control
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| | Litzelman<ref name="pmid8498761"/><br/>1993|| 395 patients<br/>• general medicine practice|| Patient and provider education||Usual care||• Any foot lesion<br/> • Serious foot lesions at one year|| Not reported||• 11%<br/>• 2.9%||<br/>• Insignificant <br/>• Significant reduction
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| | Lincoln<ref name="pmid18758747"/><br/>2008|| 172 patients<br/>• Prior ulceration<br/>• specialist clinic|| Targeted, one-to-one education ||Usual care||Re-ulceration at<br/>• 1 year<br/>2 years|| • 30%<br/>• 41%||• 20%<br/>• 41%||• Insignificant<br/>• Insignificant
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| | McCabe<ref name="pmid9472868"/><br/>1998|| 2002 patients<br/>• high-risk<br/>• general diabetic clinic|| Screening and referral to foot-care clinic if they had prior ulcer, had low ankle–brachial index (<0.75), or had foot deformities||Usual care||• Ulceration within 2 years<br/>• Amputation rates|| • 2%<br/>• 0.1%|| 4%<br/>1.2%||• Insignificant<br/>• Significant
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| | Reiber<ref name="pmid12020336"/><br/>2002|| 400 patients<br/>• Prior ulceration<br/>• Excluded severe deformity||Therapeutic shoes||Usual footwear|| Re-ulceration || 15%|| 17%|| Insignificant difference
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| |}
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| ==External Links== | | ==Case Studies== |
| * [http://diabetic-foot.net Diabetic Foot Research Page] at the Center for Lower Extremity Ambulatory Research; for Professionals and Patients
| | [[Diabetic foot case study one|Case #1]] |
| * [http://gentili.net/diabeticfoot/ Imaging of the Diabetic Foot and Its Complications]
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| * [http://www.podiatrytoday.com/article/5164 Assessing The Potential of Nitric Oxide in the Diabetic Foot]
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| * [http://www.ucihs.uci.edu/com/pathology/sherman/home_pg.htm Maggot Therapy Project]
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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]]
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| [[Category:Medicine]]
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| [[Category:Emergency medicine]] | | [[Category:Emergency medicine]] |
| [[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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