Musculoskeletal and dermatological manifestations of Diabetes

Question 1

What is the most common dermatological and MSK complication of diabetes

Answer 1

Diabetic foot ulcer

Question 2

What is the lifetime risk of a diabetic foot ulcer

Answer 2

up to 25%

Question 3

How do diabetic foot problems arise

Answer 3

secondary to neuropathy and peripheral arterial disease

Question 4

What is the usual precipitating event for diabetic foot ulcers

Answer 4

trauma

Question 5

How can sensory neuropathy be detected

Answer 5

10g monofilament

Question 6

How is the filament used

Answer 6

it is pressed against the plantar aspects of the first ad fifth toes, the first, third and fifth metatarsal heads and the plantar surface of the heel

Question 7

When should peripheral arterial disease be suspected

Answer 7

in patients with intermittent claudication
cool temperature
absence of hair and
presence of foot ulcers

Question 8

What is the normal ABPI

Answer 8

1.0-1.3

Question 9

How do we calculate ankle-brachial pressure index

Answer 9

Measuring the systolic blood pressure in the brachial, posterior tibial and doornails pedis arteries. The highest of four measurements in the ankle and feet is divided by the highest of the brachial measurements

Question 10

What does an ABPI over 1.3 suggest

Answer 10

the presence of calcified vessels which is common in diabetes

Question 11

How are diabetic foot infections diagnosed

Answer 11

At least two of the following: erythema, warmth, swelling, tenderness
Pus coming out of an ulcer site or a nearby sinus tract

Question 12

What is a mild infection

Answer 12

involvement of the skin or superficial subcutaneous tissues
erythema, warmth, swelling, tenderness,
purulence and cellulitis extending for less than 2cm around the ulcer

Question 13

What is a moderate infection

Answer 13

more extensive infection or involvement of deeper tissues
cellulitis extending >2cm around an ulcer, lymphangitic streaking, deep tissue abscess, gangrene (necrosis) or involvement of muscle, tendon, joint or bone

Question 14

What is a severe infection

Answer 14

signs of systemic toxicity or metabolic instability
fever, chills, tachycardia, tachypnoea, hypotension, confusion, vomiting and blood tests showing severe hyperglycaemia, leukocytosis, metabolic acidosis and raised urea and creatinine

Question 15

What causes gangrene (necrosis)

Answer 15

Ischaemia and is classified as wet or dry

Question 16

What causes ischaemia in wet gangrene

Answer 16

septic vasculitis associated with soft tissue infection

Tissues are black, brown or grey, moist and often malodorous

Question 17

What causes ischaemia in dry gangrene

Answer 17

peripheral arterial disease
Tissues are black , hard and mummified
Clear line between necrosis and viable tissue

Question 18

What do a lot of patients with diabetic foot ulcers also have

Answer 18

osteomyelitis

Question 19

What factors increase the likelihood of osteomyelitis in patients with diabetic foot ulcers

Answer 19

Visible bone or the ability to probe to bone
ulcer size >2x2cm
ulcer depth >3mm
Ulcer duration longer than 1-2 weeks

Question 20

What should blood tests include

Answer 20

FBC
U&E
ESR
CRP 
Blood glucose
HbA1c

Question 21

What are often the causative organisms of superficial ulcers

Answer 21

aerobic Gram positive cocci: 
staph aureus 
strep agalaciae
strep pyogenes 
coagulase negative staphylococci

Question 22

What are often the causative organisms of deep, chronic ulcers

Answer 22

gram-negative bacilli:
pseudomonoas aureginosa
proteus mirabilis

Question 23

If an ulcer has extensive local inflammation and signs of systemic toxicity, what should be presumed

Answer 23

anaerobic organisms as well as pathogens in deep chronic ulcers

Question 24

What imaging must be performed in diabetic foot infections and why

Answer 24

Foot radiograph to look for osteomyelitis

Question 25

What should be performed in patients with one or more of the risk factors for osteomyelitis and whose radiographs are indeterminate for osteomyelitis

Answer 25

MRI

Question 26

What can be seen in radiograph for chronic osteomyelitis

Answer 26

``` cortical erosion periosteal reaction mixed bony lucency sclerosis sequestra ```

Question 27

What does MRI identify in osteomyelitis

Answer 27

bone marrow oedema soft tissue inflammation cortical destruction

Question 28

What does a duplex US allow

Answer 28

anatomical localisation of arterial stenoses and assessment of blood flow haemodynamics

Question 29

What is the gold standard of diagnostic evaluation for peripheral arterial disease

Answer 29

angiography

Question 30

What does the management of a diabetic foot ulcer include

Answer 30

``` Attentive wound management and debridement antibiotic therapy relief of pressure on the ulcer revascularisation glycaemic control ```

Question 31

When should prompt surgical debridement occur

Answer 31

in the presence of a large area of infected sloughy tissue infections complicated by abscess crepitus with gas in the soft tissues on Xray purplish discolouration of the skin extensive bone or joint involvement

Question 32

What sort of devices can be used to relieve pressure on the ulcer

Answer 32

removable cast walkers half shoes total contact casts

Question 33

What are some factors that have been suggested to contribute to the pathogenesis of neuropathic arthropathy

Answer 33

peripheral neuropathy and lack of proprioception may result in ligamentous laxity Autonomic neuropathy results in vasomotor changes Exaggerated local inflammatory response to trauma

Question 34

How might patients with Charcot arthropathy present

Answer 34

a sudden onset of unilateral warmth, redness and oedema over the foot or ankle slowly progression arthropathy with insidious swelling over months or years, collapse of the arch of the midget and bony prominences and deformities

Question 35

What are some abnormalities that might be seen on a good radiograph

Answer 35

Soft tissue swelling loss of joint space osteopenia forefoot: osteolysis of the phalanges, bone resorption, partial or complete disappearance of the metatarsal head midfoot and hindfoot: osseous fragmentation, sclerosis, new bone formation, subluxation and dislocation

Question 36

What might a radioisotope scan show in Charcot arthropathy

Answer 36

Increased uptake in neuropathic arthropathy

Question 37

How is acute onset Charcot arthropathy treated

Answer 37

avoidance of weight bearing on the affected joint until oedema and erythema have resolved (minimum of 8 weeks)

Question 38

What is limited joint mobility commonly associated with

Answer 38

thickening and waxiness of the skin on the dorsal surface of the fingers

Question 39

What does the prayer sign test help to identify

Answer 39

contractures in the metacarpophalangeal proximal and distal interphalangeal joints

Question 40

How can limited joint mobility be treated

Answer 40

Tight glycaemic control physio stop smoking injection of corticosteroid into the palmar tendon sheath

Question 41

What is diabetic muscle infarction characterised by

Answer 41

an acute or subacute onset of muscle pain, swelling and tenderness, usually in the muscles of the thigh and calf

Question 42

What does a definitive diagnosis of diabetic muscle infarction require

Answer 42

biopsy of the affected area of muscle to demonstrate ischaemic encores and exclude infection

Question 43

What are the most common dermatological manifestations of diabetes

Answer 43

protracted wound healing and skin ulcerations

Question 44

How does diabetic dermopathy begin

Answer 44

erythematous areas that evolve into areas of circular hyper pigmentation

Question 45

Who are more likely to develop diabetic dermopathy

Answer 45

elderly men

Question 46

What is a dermatological sign of insulin resistance

Answer 46

acanthosis nigricans

Question 47

What is diabetic sclerodactyly characterised by

Answer 47

thickening and waxiness of the skin on the doors of the gingers and may be associated with limited joint mobility