Diabetes Education Forum 22nd Jan 08 The Diabetic Foot

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Diabetes Education Forum 22nd Jan 08 The
Diabetic Foot

• Maria Haley diabetes specialist podiatrist
• Monica Sutton diabetes specialist nurse
• Nuala Creagh - diabetologist

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Objectives of Diabetic Foot Education Forum

• Clinicians should be familiar with
• Classification of risk in the diabetic foot
• Care pathways according to risk
• Risk assessment
• The Sheffield foot assessment tool and Care
  Pathway
• Foot Care advice for people with Diabetes
• Diabetic foot problems in primary care
• referral criteria, initial management, infection
• Charcot arthropathy acute and chronic features

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Diabetic foot forum 22nd Jan 2008

• 7.20 Preventative care for the Diabetic Foot
• Classification of risk and Care Pathways
  Nuala Creagh
• 7.35 The Sheffield Risk Assessment Tool and Care
  pathway Maria Haley
• 7.55 Foot Care advice for people with Diabetes
  Monica Sutton
• 8.15 Diabetic foot problems in primary care
  Nuala Creagh
• 8.30 Discussion

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Epidemiology of the diabetic foot

• Commonest cause of hospital bed occupancy
• Foot ulcers occur in 15 diabetic patients
• gt1 undergo amputation
• Lower limb amputations ? x 15 in diabetes
• gt 50 require amputation of other limb

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Causes of diabetic foot ulceration

• lt 15 purely ischaemic
• Remainder 50 neuropathic, 50 neuroischaemic
• Neuropathy main initiating factor
• Associated with trauma and/or deformity
• Triad present in 60

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Neuropathic foot ulceration

• Typically occurs at sites of high pressure
• Metatarsal heads, plantar surface of hallux
• Apices of toes
• Between toes if footwear tight
• Heels, especially in inpatients
• Preceded by callus
• Complicated by infection
• May occur at other sites due to injury

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Clinical Guidelines Type 2 DM NICE 2004

• At annual review examination of feet should
  include
• Testing of foot sensation using 10g monofilament
  or vibration
• Palpation of foot pulses
• Inspection for any foot deformity and footwear
• Classify foot risk as
• At low current risk
• At increased risk
• At high risk
• Ulcerated foot

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Classification of risk in the diabetic foot

• Low current risk
• normal sensation, palpable pulses
• Increased risk
• neuropathy or absent pulses or other risk factor
• High risk
• neuropathy or absent pulses
• deformity or skin changes (callus) or previous
  ulcer
• Foot care emergencies and foot ulcers
• new ulcer, swelling, discolouration

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Foot care according to level of risk 1

• Low current risk (normal sensation, palpable
  pulses)
• Agree a management plan including foot care
  education with each person
• Increased risk (neuropathy or absent pulses or
  other risk factor)
• Regular review, 3-6 monthly, by foot protection
  team
• At each review
• Inspect feet
• Consider need for vascular assessment
• Evaluate footwear
• Enhance footcare education
• ie regular podiatry and footcare advice

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Foot care according to level of risk 2

• High risk (neuropathy/absent pulses deformity
  or skin changes or previous ulcer)
• arrange frequent review 1-3 monthly by foot
  protection team
• Inspect feet
• Consider need for vascular assessment
• Evaluate and ensure appropriate provision of
• Intensified foot care education
• Specialist foot wear and insoles
• Skin and nail care
• ie regular podiatry, footcare advice and
  orthotics referral

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Foot care according to level of risk 3

• Foot care emergencies and foot ulcers (new ulcer,
  swelling, discolouration)
• Refer to multidisciplinary foot team within 24hrs
• Expect that team as a minimum to
• Investigate and treat vascular insufficiency
• Initiate and supervise wound management
• Use dressings and debridement as indicated
• Use systemic antibiotics for cellulitis or bone
  infection as indicated
• Ensure an effective means of distributing foot
  pressures including specialist footwear,
  orthotics and casts

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Pathways of footcare in Sheffield primary care

• Risk assessment at annual review by practice
  nurse/GP
• If not competent at risk assessment, request
  training refer patient to podiatry for risk
  assessment
• Low current risk
• Basic footcare advice
• refer to podiatry for group education session or
  if unable to care for own feet
• Increased risk
• Inspect feet 3 6 monthly
• Enhance foot care education
• Refer podiatry
• High risk
• as increased risk refer for assessment for
  special footwear

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Diabetic foot problems in primary care

• Referral Criteria
• Initial management including infection
• Charcot Arthropathy
• Amputation

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Foot care emergencies and foot ulcers refer to
foot care team within 24 hours

• Primary care guidelines for referral to foot
  clinic
• diabetic foot ulcer/necrotic lesion
• callus with local infection
• nail pathology with ischaemia and infection
• suspected Charcot arthropathy
• undiagnosed foot problem in At Risk foot
• high risk feet for assessment for special
  footwear
• Emergency referral same day review or admit
• Spreading cellulitis, abscess, wet gangrene

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STH Foot clinics

• NGH
• Mon am 9am 1pm
• Tues pm podiatry led
• Wed am podiatry led
• RHH
• Tues pm 1.30 5pm
• Mon am podiatry led
• Wed am podiatry led
• Thurs am podiatry led

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Diabetic foot problems in primary care

• In all cases assess foot
• ? history of injury
• ? neuropathic, ischaemic, neuroischaemic
• For evidence of infection
• Nb. The combination of infection and ischaemia
  is dangerous and may cause rapid tissue loss

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Initial management of diabetic foot ulcers

• Definition
• Full thickness break in skin below level of
  malleoli
• Start antibiotics if any evidence of infection
• Swab foot ulcer base after cleansing
• Dressing
• Non adherent, avoid adhesive tape in ischaemic
  feet
• Relieve pressure avoid weight bearing if
  plantar
• Refer diabetic foot clinic within 24 hours

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Diabetic foot problems - infection

• Spectrum from local infection to spreading
  life-threatening sepsis
• Infected ulcer
• Yellowy/grey base, discharge, odour
• Sinuses/ exposed tendon or bone
• Mild cellulitis (lt3cm)
• Local erythema, warmth, swelling
• Severe cellulitis (gt3cm)

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Infecting organisms in diabetic foot infections

• Mild cellulitis usually staphylococci/streptococ
  ci
• Deep infections/osteomyelitis often mixed
• staphylococci/streptococci
• Gram negative bacilli, eg E Coli, Proteus
• anaerobes

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Diabetic foot infections

• First line antibiotics in primary care
• Augmentin 625mg tds or Flucloxacillin 500mg qds
• If penicillin allergic
• Clindamycin 300mg qds most effective but
  caution in frail/elderly
• Clarithromycin 500mg bd
• Cephalexin 500mg tds, unless h/o anaphylaxis
  with penicillin
• If deep ulcer/odour, consider metronidazole

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Diabetic foot infection important practice
points

• Complicates ulcers, rapid tissue loss with
  ischaemia
• Low index of suspicion, detect and treat early
• Diabetes specialist podiatrists may request
  prescription of antibiotics in community
• Osteomyelitis frequently requires 3 months or
  more antibiotics
• Prolonged antibiotics may also be indicated in
  critical ischaemia/ deep foot ulcers

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Diabetic foot infection - Osteomyelitis

• Complicates deep ulcers, often associated with
  cellulitis
• Present if bone exposed or can probe to bone
• Typical sausage toe appearance
• Bony pain and tenderness typical
• Usually diagnosed clinically or by serial xrays
• Treatment medical unless extensive tissue loss,
  septic arthritis, abscess

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Callus

• Callus, particularly plantar, hallmark of
  neuropathic foot
• Callus may overly ulcer
• If uncomplicated callus, refer urgently to
  podiatry
• If evidence of local infection, start antibiotics
  and refer to foot clinic

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Nail pathology

• Ingrowing, involuted toe nails refer podiatry
• Antibiotics if local infection
• Nail pathology with infection and ischaemia
  refer foot clinic
• Fungal infection of nails
• refer podiatry for debulking
• 3/12 course lamisil if spreading, painful,
  cosmetically unacceptable

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Diabetic foot problems - blisters

• Caused by trauma, usually inadequate footwear/
  failure to wear socks
• In neuropathic/neuroischaemic feet
• Show need to review footwear
• May lead to ulceration
• Leave intact if no evidence of infection
• If associated infection cloudy fluid/local
  cellulitis
• Cover with dressing
• Antibiotics
• Refer urgently to foot clinic

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Non infective causes of red toe/foot

• Acute Charcot arthropathy
• Ischaemia
• Neuroischaemic diabetic foot may not be cold
• Erythema more pronounced on dependency
• Gout
• Fracture
• If doubt re diagnosis in at risk foot refer to
  foot clinic

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Charcot arthropathy

• Destructive arthropathy
• Complication of peripheral neuropathy
• Results in gross deformity and risk of ulcers
• Early immobilisation reduces extent of deformity

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Charcot arthropathy acute phase

• Presents with redness and swelling foot /- leg,
  /- pain
• May be history of minor injury
• May follow fracture or surgery
• mimics cellulitis, gout, osteomyelitis, DVT

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Charcot arthropathy - management

• High index of suspicion if red, warm, swollen
  neuropathic foot
• Immobilise ie no weight bearing refer next
  foot clinic
• Pamidronate infusion
• Continue immobilisation for 6 months
• Plaster of Paris, aircast walker

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Amputation

• Major amputation, below knee or above usually
  in the critically ischaemic foot
• gangrene
• severe sepsis or
• severe ischaemic rest pain
• Neuropathy alone rare cause of major amputation
• Severe sepsis and foot unsalvagable
• Severely disrupted ankle of Charcot arthropathy

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Amputation

• Minor amputation of toe(s), transmetatarsal
• osteomyelitis complicating neuropathic ulceration
• For ischaemic ulceration/gangrene following
  revascularisation
• Autoamputation of dry gangrenous toes may occur

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To conclude. Practice points and pitfalls

• Neuropathic foot may be symptomless
• Need for diabetic foot risk assessment
• Neuropathic ulceration
• Callus may obscure underlying neuropathic ulcer
• Ischaemia
• neuroischaemic foot may not be cold
• Acute Charcot arthropathy
• suspect if warm, swollen neuropathic foot

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To conclude Practice points and pitfalls 2

• Refer all new diabetic foot ulcers within 24
  hours of presentation
• Infection
• Treat early, low index of suspicion especially if
  ischaemia
• Prolonged courses often necessary
• May need to prescribe at request of podiatrists