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Objectives Unlocking the Mystery of Diabetic Foot Pathology 1.
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Donna Flahr RN BSN IIWCC MSc (WHTR) Wound Care Expert and Consultant
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Why is this topic important? 
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The Saskatchewan Diabetes Cost Model estimates that 75,000 people in Saskatchewan have been diagnosed with type 1 or type 2 diabetes in 2010 – 7.0% of the population. This number is expected to increase by 36,000 over the next decade to 111,000 or 9.9% of the population of Saskatchewan.
To give an overview of diabetic statistics.
To recognize the importance of blood glucose management in foot health.
To discuss the vascular changes that occur over time in the diabetic limb.
To outline the potential structural and neuropathic changes that can occur in diabetes.
To describe the immune system alterations that can occur in the diabetic patient.
To discuss the key components of diabetic foot ulcer management.
To recognize when surgery might be an option. Saskatchewan Statistics 
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The economic burden of diabetes in Saskatchewan is estimated to be $419 million in 2010.
This cost is expected to increase by 27% over the next decade to $532 million by 2020.
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More Statistics 
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Cost annually spent on diabetes in Canada $10 billion. Average cost $9,000 per Diabetic Foot Ulcer if Evidence‐Based Practice is not used.
Lower limb amputations are 11 times higher in persons with diabetes. Prevention is Key! 
Approximately 15% of all diabetics will develop a
foot ulcer at some time during the course of their
disease.
Eighty-five percent of lower limb
amputations are preceded by foot ulcers.
Involve the Dietitian Early 
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Hyperglycemia alters the immune response.
Dietician involvement is an essential part of foot ulcer and infection prevention/management in persons with diabetes (PWD).
Good nutrition facilitates immune competence, supports healing and decreases infection risk.
So what changes will we eventually see
in the lower limb?
Diabetic distal symmetric polyneuropathy
Involves all peripheral nerves
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Sensory
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Autonomic
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Motor
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Sensory Neuropathy
Sensory neuropathy =
Loss of Protective Sensation (LOPS)
Diabetic Foot Screen 
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Inability to detect the pressure of the monofilament at any site (unless there is callous), indicates sensory neuropathy and the loss of protective sensation (LOPS). LOPS puts the foot at 7x the risk of ulceration.
This skin ulceration risk is even higher if there are bone deformities or signs of poor circulation.
Note: Light touch is often intact
Autonomic Neuropathy
Motor Neuropathy
Autonomic neuropathy is caused by damage to the nerves heart and lungs (BP changes, SOB with exercise) sweat glands, resulting in dry skin and excess callous formation (hyperkeratosis).
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Motor neuropathy effects the nerves controlling the motion of the foot.
Result: intrinsic muscle atrophy, changes in the alignment of the foot and resultant deformities.
Dry cracked skin and callus formation may result in
ulceration and limb threatening infection!
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To Sum it Up!
So How Can We Have an Impact! It is mandatory that the patient is informed early
about the risks to the feet associated with
diabetes.
Footwear
Remember Shoes should have a deep toe box and be low heeled.
Ulcers on the non‐weight bearing surfaces are likely friction injuries and may be
directly linked to poorly fitting footwear
Patients should be fit for footwear late
in the day when their feet are slightly
swollen.
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Shoes and Stones
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Diabetic patients should be encouraged to wear their shoes indoors as well as out.
Teach patients to check their footwear for foreign bodies prior to putting them on.
The Importance of Lower Limb Assessment 
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Peripheral pulse palpation
Capillary refill
ABPI
So Now Let’s Talk About Diabetic Foot Ulcers Usually seen as a result of peripheral neuropathy and
peripheral vascular disease.
Wound Assessment 
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Location
Cause Size, wound base and margins Probe for depth and the presence of bone
LOOK AT BOTH LIMBS AND COMPARE!
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Goals of Treatment 
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Callous debridement Pressure management
Appropriate wound management
Recognition and management of infection Early recognition of ischemic changes and referral Medical management of co‐morbidities
Surgical management
Podiatry Role
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Podiatrists are expert at callous debridement and pressure management in Diabetic foot ulcers; they are an integral member of the treatment team.
Types of Debridement  Autolytic  Enzymatic  Mechanical  Surgical –
evidence‐based, selective, rapid (requires advanced training)  A wound may actually increase in size during the debridement process Pressure Management 
Includes callus debridement 
Essential to healing!!
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The Importance of Offloading Dressing Selection Ulcers on the weight‐bearing surface
of the foot will only heal with proper
offloading Select appropriate dressings for local moisture
balance and healing.
 Choose a dressing that protects the peri‐wound skin and keeps the ulcer bed moist.
 Choose a dressing that controls exudate.
 Re‐assess the wound and change dressings as required to achieve optimal moisture balance.
 Consider caregiver time in dressing choice.  THERE ARE NO SILVER BULLETS!
Pearls 
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Protect intact surrounding skin from wound exudate (think Skin Prep™, No Sting™). Apply dressings with a minimum of 2 cm. on good skin to reduce the risk of maceration.
Consider antimicrobials early and in 2 week increments.
Provide thermal insulation by warming cleansing solutions and reducing the frequency of dressing changes.
We need to find a balance!!
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Optimal ‐ ideal moisture balance assists in decreasing inflammation, increases cell proliferation and increases the rate of epithelialization
Too much moisture ‐ maceration, increased tissue damage, increased risk of infection, reduction in cell proliferation.
Too little moisture ‐ inhibits re‐epithelialization
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INFECTION IDENTIFICATION AND MANAGEMENT 
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clinical signs and symptoms semi‐quantitative swabs topical antimicrobial application trial of systemic antibiotics
To Swab or Not To Swab 
Wound swabs can not only relay important information re antibiotic sensitivities to assist in guiding treatment, they are important as a tool in wounds that are not progressing to assess for the presence of resistant organisms.
Obtaining a Culture 
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Cleanse the wound with normal saline or sterile water prior to taking the swab. Don’t culture eschar or exudate.
Center the swab in the deepest part of the wound, and using sufficient force to initiate bleeding, rotate the swab in place.
Clinical Indicators of Infection 
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A 2 cm. erythematous border A large amount of drainage despite best practice.
Pain in a previously insensate foot.
A sudden spike in blood sugars
Increased WBC or ESR
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Antibiotic Lotions and Potions Antimicrobial Dressing Use Routine use of topical antimicrobial creams and ungts aren’t advised for longer than 14 days, they contain potential sensitizers; they can also increase the risk of resistance with long term use.
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Trial of Systemic Antibiotics
Don’t Forget the Role of the Surgeon! 
If you have been following evidence supported best practice: offloading, pressure reduction, nutritional correction, pain management and the wound still fails to progress it may be appropriate to intervene with a trial of systemic antibiotic therapy
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Antimicrobial dressings should be used for infected wounds or wounds that are at high risk of infection or reinfection. It is recommended that antimicrobial dressings be used for an initial two week 'challenge' period after which the wound, patient and management approach should be re‐evaluated. Re‐vascularization techniques have excellent outcomes in diabetic patients and access to these procedures should not be restricted in the diabetic patient population. There have been studies post bypass graft in diabetics that indicate patency rates as high as 92% after 3 years, with a corresponding limb salvage rate of 96%. In a 2006 meta‐analysis primary patency rates were pooled at 63.6%, secondary patency at 70.7% and 77.7% limb preservation.
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When Surgery Is Not An Option
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Conservative treatment for ischemia management: leave the eschar/scab intact on a wound, paint the wound with Betadine or Chlorhexidine and keep it dry. Conservative Treatment for Ischemia
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No Foot Soaks!!
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Pain Relief Options
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Trans Electrical Nerve Stimulation (TENS) or High Voltage Pulsed Current (HVPC) may be helpful – both require a PT specializing in electrotherapy ASA therapy, weight loss and exercise as tolerated (increase collateral circulation)
wearing thick socks
raising the head of the bed to increase gravitational flow
smoking cessation lipid control BP management
pain relief.
Pain Management Often there is a neurological pain component that may need to be managed through the use of drugs like:
 Desipramine
 Amitriptylline and  Nortriptylline
Other possible agents:  Gabapentin
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Client Advocacy 
Diabetes is a multisystem disease.
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We need to advocate for this population.
Considerations Try and maximize healing recognizing:
 Patient’s choice
 The patient/family ability to change circumstances
 Consider best practice
 Local support systems We Can’t Do This Alone! 
Interdisciplinary teams are the Gold Standard of Diabetic Foot Ulcer management and something that we , as health care professionals, should be working toward Good Job! Don’t forget “hole”istic care!
TTT – Things Take Time
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References 
Canadian Diabetes Association (2009) The Cost of Diabetes in Saskatchewan
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Orsted et al. (2006) The Art and Science of Wound Care: Fundamentals of
Wound Management. Mölnlycke Health Care.
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Laubscher T (2010) Prevention and Management of Diabetic Foot
Complications. U of S Continued Professional Learning Conference
Presentation
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Laing P (1998) The development and complications of diabetic foot ulcers The
American Journal of Surgery 176: (Suppl 2A): 11S-19S.
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Stonebridge PA, Murie JA (1993) Infrainguinal revascularization in the diabetic
patient British Journal of Surgery 80: 1237-1241.
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CAWC conference November 4-7, 2010, Calgary AB
References cont’d 
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Report of the Saskatchewan Advisory Committee on Diabetes. Diabetes 2000:
Recommendations for a Strategy on Diabetes Prevention and Control on Saskatchewan Houghton P, Koso C, Schulz V. Assessing and Managing Arterial Ischemic Pain. Wound Care Canada. 11(1); 31‐32. International Consensus. 2012. Appropriate use of silver dressings in wounds. An expert working group consensus. London. www.woundsinternational.com
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