Diabetic Foot Care
Marianne Misiewicz, DPM,
AACFAS
Columbia, MO
STATISTICS
• 24 million Americans have diabetes,
approximately 7% of the population (CDC 2008)
• 15-25% will develop ulcers on their feet.
• 20% of diabetics admitted to hospitals
because of foot problems
• Nearly $98 billion spent annually for direct
and indirect medical costs(1997).
O’Brien, JA, et al. “Direct Medical Costs of Complications Resulting from Type 2 Diabetes in the US.”
Diabetes Care vol 21 #7, July 1998.
STATISTICS
• 625,000 new cases of diabetes/year
• 178,000 deaths/year from disease and
related complications.
• Nearly half of nontraumatic LEA caused by
diabetes.
• Average acute hospital cost in 1996 for a
foot ulcer 9,910.
• 5 year survival rate ~50% for BKA
O’Brien, JA, et al. “Direct Medical Costs of Complications Resulting from Type 2 Diabetes in the US.” Diabetes Care
vol 21 #7, July 1998.
STATISTICS
• ~50% of diabetics with LEA require 2nd
LEA within 5 years of initial amputation.
• Often require care outside of hospitalization
(80%) including:
Prosthetic device
Physician visits
Wound care/Home Health
O’Brien, JA, et al. “Direct Medical Costs of Complications Resulting from Type 2 Diabetes in the US.” Diabetes Care vol
21 #7, July 1998.
STATISTICS
• Greater than 50% of all non-traumatic
amputations are diabetics
• 0.5 billion dollars for hospital and surgical
costs per year
• 5 year survival rate ~50% s/p amputation.
STATISTICS
• Diabetes is the 4th leading cause of death by
disease in the United States
• Diabetics are 2-4 times more likely to
experience heart disease and strokes
• Is the leading cause of ESRD
• Is the leading cause of blindness in adults >
75 y/o.
• ~53% of family physicians reported
adherence to semi-annual foot exams for
patients with Type II diabetes
• ~64% reported adherence with Type I
diabetics.
Sussman, KE. "The Diabetic Foot
Problem-A Failed System of Health
• Fewer than 20% of diabetic patients are
regularly given foot examinations by their
primary care physicians
Sussman, KE. "The Diabetic Foot
Problem-A Failed System of Health
FOOT EXAM
1.
2.
3.
4.
5.
Skin & Integument
Vascular
Neurological
Musculoskeletal
Shoegear
FOOT EXAM
1. Skin and Integument
A. Color
B. Temperature
C. Texture
D. Hair Growth
E. Moisture
F. Lesions-location, size, type
G. Condition of toenails
FOOT EXAM
2. Vascular exam
A. Color
B. CFT
C. Varicosities/Edema
D. Pulses (DP and PT)
FOOT EXAM
3. Neurological
A. Light touch
B. Sharp-dull discrimination
C. Vibratory
D. Proprioception
E. Protective sensation
F. DTR
FOOT EXAM
4. Musculoskeletal
A. General appearance(gross deformities)
B. Muscle strength/function
C. Muscle tone
D. ROM
FOOT EXAM
5. Shoe Gear
A. Everyday shoe style
B. Dress shoe style
C. Exercise shoes
D. Shoe inserts/orthoses
E. Special shoe needs
SHOES
SUPPORTIVE DEVICES
COMMON FOOT AILMENTS
AND THEIR TREATMENTS
1.
2.
3.
4.
Toenails
Corns/Calluses
Xerosis
Bunions/Hammertoes/other
musculoskeletal problems
COMMON FOOT AILMENTS
AND THEIR TREATMENTS
5. Vascular disease
6. Neuropathy
7. ULCERATIONS
TOENAILS
1. Onychomycosis=Fungal nails
2. Onychocryptosis=ingrown nail
3. Onychogryphosis=thickened(Ram’s horn)
nail
4. Onycholysis=crumbly nail
5. Onychia/Paronychia=abscessed/infected
nail
CORNS
CALLUSES
1.
2.
3.
4.
Location
Cause
Treatment
Prevention
CALLUSES
CAUSE=PRESSURE
Usually a bony prominence
CALLUSES
MEASURES TO ELIMINATE PRESSURE
POINTS
1. Podiatric consultation for debridement
2. Shoe modifications, insoles, orthotics
3. Elective surgery on deformity
HALLUX ABDUCTOVALGUS
AKA-BUNIONS
HAMMERTOES
HAMMER DIGIT SYNDROME
VASCULAR DISEASE
1. ARTERIAL DISEASE
A. Large vessel
B. Small vessel
C. Microvasculature
2. VENOUS DISEASE
A. Varicosities
B. Venous stasis
NEUROPATHY
1. PERIPHERAL SENSORY
NEUROPATHY
2. MOTOR NEUROPATHY
3. AUTONOMIC NEUROPATHY
PERIPHERAL SENSORY
NEUROPATHY
A. “Glove and Stocking” distribution
B. Paresthesia
C. Anesthesia
MOTOR NEUROPATHY
A. Weakness, atrophy, foot drop
B. Structural deformities(ie hammertoes, pes
cavus)
AUTONOMIC NEUROPATHY
A. Sympathetic Failure-microvascular
dilation
B. Anhidrosis
ULCERATION
WAGNER CLASSIFICATION FOR
DIABETIC FOOT LESIONS
Grade 0 – No open lesion(callus may be
present)
Grade 1 – Superficial Ulcer
Grade 2 – Deep Ulcer to Tendon, Capsule or
Bone
ULCERATION
WAGNER CLASSIFICATION FOR
DIABETIC FOOT LESIONS
Grade 3 – Deep Ulcer with abscess,
osteomyelitis, joint sepsis
Grade 4 – Localized gangrene
Grade 5 – Gangrene of entire foot
ULCERATIONS
•
•
•
•
•
•
DESCRIPTION
SIZE(L x W x D)
DURATION
LOCATION
DRAINAGE/INFECTION
ODOR
BASE/RIM
ULCERATIONS
1.
2.
3.
4.
5.
TREATMENT PROTOCOL
GRADE 0
Proper shoe/orthotics
Education
Palliative Podiatric care
Prophylactic surgery
Prevention
ULCERATIONS
1.
2.
3.
4.
5.
TREATMENT PROTOCOL
GRADE 1
Antibiotic therapy
Wound care
Radiographs
Surgery
Same as Grade 0
ULCERATIONS
TREATMENT PROTOCOL
GRADE 3
1.Hospitalize/IV abx
2.Aggressive I&D/Debridement
3.Radiograph/Bone scan/MRI – r/o OM
4.Metabolic control
5.Plastic surgical closure prn
CONCLUSION
1.
2.
3.
4.
5.
PREVENTION – “CYA”
Multidisciplinary team-coordinated by
PCP
Patient education
Daily foot inspections by patient
Shoegear changes
Elective surgery to decrease risk
References:
• O”Brien JA, et al. “Direct Medical Costs of
Complications Resulting From Type 2
Diabetes in the US.” Diabetes Care 1998
21:7 pp 1122-8.
• Sussman, KE. “The Diabetic Foot ProblemA Failed System of Healthcare?” Diabetes
Res Clin Pract 1992;17:1-8.
• Saar WE, Lee TH, Berlet GC. “The
Economic Burden of Diabetic Foot and