L6: Diabetic Foot

Question 1

Def of Diabetic Foot

Answer 1

• Infection, ulceration or destruction of deep tissues associated with neurological abnormalities & various degrees of peripheral vascular diseases in the
  lower limb (based on WHO definition)

Question 2

Epidemeology of Diabetic Foot

Answer 2

Question 3

Pathophysiology of Diabetic Foot

Answer 3

Question 4

Pathogenesis of Neuropathy

Answer 4

• Changes in the vasa nervosa
• Metabolic disorders with release of nerve toxic substance ( e.g. end glycation product)

Question 5

what types of nerves does neuropathy affect?

Answer 5

• Motor Nerves
• Autonomic nerves
• Sensory nerves (most important)

Question 6

Motor nerves affection in neuropathy (Diabetic Foot)

Answer 6

wasting of small muscles of the foot ——> foot deformities —–> abnormal pressure area

Question 7

Autonomic nerves affection in neuropathy (Diabetic Foot)

Answer 7

• Dryness of the skin and loss of sweat and oil secretion which leads to excessive callus formation and skin cracks.
• Loss of neurogenic component of inflammatory response blunted inflammatory response and less severe signs of a severe infections.

Question 8

Sensory nerves affection in neuropathy (Diabetic Foot)

Answer 8

• Sensory loss of superficial and deep sensation is the
  most important part of sensory affection
• Patients are unaware of trauma to the foot (loss of
  protective mechanism) pressure sores over weight bearing points of the foo

Question 9

Pathogenesis of Ischemia in DM

Answer 9

• Accelerating atherosclerosis in diabetic patients
• Usually atherosclerosis affects small size arteries (anterior tibial, posterior tibial and dorsalis pedis)

Question 10

Pathophysiology of infection in DM

Answer 10

Peripheral Neuropathy
- Sensory and autonomic neuropathy provides site of
entry of organisms and blunt neurogenic immune
response.

Metabolic
- Hyperglycemia a state of immuno-suppression

Question 11

Diabetic foot microbiology

Answer 11

• Usually in limb threatening diabetic foot infections there is polymicrobial bacterial infection with gram positive, gram negative, and anaerobic bacterial
  infection .

Question 12

Clinical Picture of Diabetic Foot

Answer 12

• Trophic ulcers (either ischemic or neuropathic)
• Dystrophic changes
• Gangrene & previously amputated toes or foot

Question 13

Compare between Ischemic & Neuropathic Ulcers in terms of:

• Site
• Temperature
• Sensation
• Pulse
• Pain
• Deformity

Answer 13

Question 14

Examination of Diabetic Foot

Answer 14

• Dermatological
• Neurological
• Vascular

Question 15

Dermatological assessment of Diabetic Foot

Answer 15

Question 16

Neurological assessment of Diabetic Foot

Answer 16

Question 17

Vascular assessment in Diabetic Foot

Answer 17

Dorsalis pedis and posterior tibial artery examination

Question 18

Investigations in Diabetic Foot

Answer 18

• DM
• CBC
• Culture & Sensitivity

Question 19

Imaging studies in Diabetic Foot

Answer 19

• Plain X ray
• MRI scan
• Bone scan and radio-active labeled leukocyte scan
• Pedobarography

Question 20

Plain X ray in Diabetic Foot

Answer 20

it is the basic study in all patients with diabetic foot it can show:

• osteomyelitis, bone fractures, joint dislocations
• foreign bodies
• gas due to gas forming infections
• soft tissue inflammatory hypertrophy

Question 21

MRI in Diabetic Foot

Answer 21

• very sensitive in detecting the extent of soft tissue infection and bone and joint involvement

Question 22

Bone scan and radio-active labeled
leukocyte scan Diabetic Foot

Answer 22

are of low clinical importance

Question 23

Pedobarography in Diabetic Foot

Answer 23

Computerized method to detect points of high pressure in patients with neuropathic ulcers

Question 24

Vascular scan in Diabetic Foot

Answer 24

• Duplex Scan
• Angiography
• MRA

Question 25

Duplex scan in **Diabetic Foot**

Answer 25

- can be done to evaluate blood vessels in non-limb threatening infections and in follow up

Question 26

Angiography in **Diabetic Foot**

Answer 26

- It is done when planning for vascular reconstruction in case of ischemic diabetic infections

Question 27

MRA in **Diabetic Foot**

Answer 27

- Is used in case of severe renal impairment and severe dye hypersensitivity which is not uncommon in diabetics

Question 28

Diabetic Foot Ulcer Control

Answer 28

Question 29

Metabolic Control for **Foot Ulcer**

Answer 29

- In all stages tight Glycemic control is important. - Insulin therapy based - Control of BP, Dyslipidemia & Cessations of Smoking is required.

Question 30

Mechanical Control for **Foot Ulcer**

Answer 30

- Off-loading ----> neuroischemic ulcers healing

Question 31

Educational Control for **Foot Ulcer**

Answer 31

- Routine foot care for all diabetics. - Prophylactic diabetes foot ware & trauma Prevention education to high risk patient. - Education regarding early sign of infection & immediate reporting. - Rehabilitation & Psycho-social support in patient with major Amputation

Question 32

Vascular Control for **Foot Ulcer**

Answer 32

- In severe ischemic foot attempts to improve vascular perfusion by angioplasty or bypass surgery

Question 33

TTT of **Diabetic Foot**

Answer 33

- TTT pf neuropathic ulcer - TTT of infection

Question 34

TTT of Neuropathic ulcers

Answer 34

Question 35

TTT of infections in diabetic foot

Answer 35

Question 36

what is the corner stone in treatment of diabetic foot infection?

Answer 36

Surgical drainage

Question 37

Foot Care in Diabetic Foot

Question 38

Joints can be affected by neuropathy resulting in the so called Charcot foot -----> It is painless progressive degenerative arthropathy

Answer 38

..

Question 39

Causes of **Neuropathic Arthropathy (Charcot Joint)**

Answer 39

loss of proprioceptive and pain sensation -----> loss of foot architecture & deformity ----> abnormal press diabetic foot

Question 40

CP of **Neuropathic Arthropathy (Charcot Joint)**

Answer 40

- Swelling and deformity - Signs of inflammation. - Profound unilateral swelling - Increase in localized temp - Erythema - Joint effusion - Unequal dorsalis pedis artery

Question 41

MAnagement of **Neuropathic Arthropathy (Charcot Joint)**

Answer 41

**Radiology:** - X-ray & MRI **Therapy:** - Diabetic control - Bisphosphonate therapy - Off loading - Surgery