Clinical approach to case of diabetic foot

By Dr.Moenes Moh.Khairy Consultant of vascular surgery KFHU

Introduction
Diabetic patients are more prone to:
1)Neuropathy. 2)Peripheral vascular disease.

3)Infection.

Diabetic neuropathy is characterized by: 1)Sensory Neuropathy which leads to loss of pain sensation (protective mechanism against injury). 2)Motor Neuropathy which leads to paralysis of the intrinsic muscles of the foot which leads to high medial longitudinal arch ( pes cavus ), prominent metatarsal heads and claw toes. This deformity together with loss of protective sensation leads to increased pressure at the metatarsal heads which ends in callus formation and ulceration. 3)Autonomic Neuropathy which leads to loss of sweat, dry skin, fissure formation and infection.

The absence of sensation may be determined using a tuning fork, pin prick, piece of cotton and hot and cold rods. Motor neuropathy can be determined by active movements and active movements against resistance to detect the muscle power. Autonomic neuropathy can be determined by absence of sweating.

Autonomic neuropathy can lead to loss of sympathetic tone with vasodilatation and demineralization of bones. The bones become soft and they are subjected to minor trauma due to sensory neuropathy leading to sublaxation and displacement of the joints of the foot. Also the soft bones of the foot are subjected to pressure by the body weight so fractures of these soft bones can occur. Diabetes also affects the resiliency of the Achilles tendon, thereby pulling the foot into equinus which increases forefoot pressure (with increased risk for ulceration) and this leads to midfoot collapse, rockerbottom deformity and Charcot arthropathy.

Shortening or loss of natural extensibility of the Achilles tendon may lead to pulling of the foot into plantarflexion. This leads to increased forefoot pressure (increasing risk for plantar ulceration)and, in some patients, may be a component of midfoot collapse and Charcot arthropathy.

Vascular assessment must include palpation of all lower extremity pulses, including femoral, popliteal, posterior tibial, and dorsalis pedis pulses. If dorsalis pedis pulse is present the limb is not ischemic. If dorsalis pedis pulse is absent check post.tibial pulse. If absent check popliteal and femoral pulse to detect the level of obstruction and do duplex with A/B index to assess the condition of the collaterals.

systolic ankle pressure ABI = systolic arm pressure

In diabetic ischemic patient, the ABI is falsely elevated. so the peripheral circulation can be assessed by measuring the toe systolic pressure and transcutaneous oxygen tension.

So examination of diabetic foot consists of:

*Introduction to the patient

*Exposure of the patient from umbilicus downwards.

Swelling Deformity ulcers Fissured dry scaly skin infection Presence of hair, muscle wasting, brittle nails or gangrene

- Test for the sensory nerves using pin prick and tuning fork. - Test for the motor nerves using active movements and active movements against resistance. - Test for the autonomic nerves by palpating the skin for sweating. - Palpate all the pulses including dorsalis pedis, posterior tibial,popliteal and femoral pulses. - Look for interdigital fungal infection,osteomyelitis and superficial inguinal lymphadenopathy.

Thank You