Diabetic foot - BMJ

1 CLINICAL UPDATES. Diabetic foot BMJ: first published as on 16 November 2017. Downloaded from on 31 January 2022 by guest. Protected by copyright. Satish Chandra Mishra,1 Kunal C Chhatbar,2 Aditi Kashikar,3 Abha Mehndiratta4. 1. Department of Surgery, Bhabha Atomic Research Centre Hospital, Mumbai, India 2. KHM Hospital, Mumbai, India 3. Seth Gordhandas Sunderdas Medical College and King Edward Memorial Hospital, Mumbai, India 4. Global Health and Development Group, Imperial College London, St Mary's Hospital, London, UK. Correspondence to: A Mehndiratta Foot disease affects nearly 6% of people with Sources and selection criteria diabetes1 and includes infection, ulceration, or This clinical update is based on recommendations in the destruction of tissues of the It can impair standard treatment guideline, The Diabetic foot.

2 Prevention patients' quality of life and affect social participation and management in India 2016, published by the Indian and Between and of Ministry of Health and Family A multidisciplinary patients with Diabetic foot require an guideline development group consisting of surgeons, primary Most ulcers can be prevented with good foot care care practitioners, and a patient representative developed and screening for risk factors for a foot at risk these guidelines, with inputs from experts in diabetes, Diabetic foot rehabilitation, and vascular surgery.

3 The group of We provide an update on the included representation from rural and urban India, and prevention and initial management of Diabetic foot in public and private sectors. primary care. The guideline development group selected recommendations from the National Institute for Health and Care Excellence What causes Diabetic foot? clinical guideline 19. Diabetic foot problems: prevention Uncontrolled diabetes contributes to the development of and management. Updated 2016, International Working neuropathy and peripheral arterial disease by complex Group on the Diabetic Foot guidance on the prevention of metabolic Loss of sensation caused by foot ulcers in at-risk patients with diabetes 2015, National peripheral neuropathy, ischaemia due to peripheral Institute for Health and Care Excellence.

4 Peripheral arterial arterial disease, or a combination of these may lead disease: diagnosis and management. Guideline 147, 2012, to foot ulcers. A systematic review (78 studies from and Infectious Diseases Society of America clinical practice 84 cohorts) reports a prevalence of for guideline for the diagnosis and treatment of Diabetic foot diabetes related peripheral neuropathy and infections, 10 21 32 Some recommendations were for diabetes related peripheral arterial Figure 1 adopted unchanged, whereas others were adapted taking into account the challenges of a low resource setting, such depicts factors that contribute to foot complications.

5 As availability of public and private health infrastructure, Diabetes is also implicated in Charcot arthropathy, equipment, staffing, and current capacity at different levels which involves progressive destruction of the bones, of care. joints, and soft tissues, most commonly in the ankle and foot. Diabetes related Charcot's arthropathy has a reported prevalence between and 13%, but there are no high quality epidemiological studies on In low and middle income countries barefoot walking, Charcot's 8 A combination of neuropathy, abnormal lack of awareness, delay in seeking care, and shortage of loading of foot, repeated micro trauma, and metabolic trained healthcare providers and foot care services are abnormalities of bone leads to inflammation, causing common factors that add to the burden of foot disease.

6 Osteolysis, fractures, dislocation, and How is it diagnosed? A thorough foot examination is important to detect the disease early. Screening for peripheral neuropathy and What you need to know peripheral arterial disease can help identify patients at risk Diabetic foot can be prevented with good of foot ulcers. A history of ulcers or amputations and poor glycaemic control, regular foot assessment, glycaemic control increase the risk. appropriate footwear, patient education, and Assess the patient's general condition for signs of early referral for pre-ulcerative lesions toxicity or sepsis such as feeling unwell, looking sick, Examine the feet of people with diabetes showing abnormal behaviour, circulation, or respiration, for any lesions and screen for peripheral with or without fever.

7 Examine the feet at each follow-up neuropathy and peripheral arterial disease, visit for active disease such as ulceration or gangrene which can lead to injuries or ulceration Refer patients with foot ulceration and signs of infection, sepsis, or ischaemia immediately to a How patients were involved in the creation of P. specialised Diabetic foot centre for surgical care, this article revascularisation, and rehabilitation No patients were involved in the creation of this article. the bmj | BMJ 2017;359:Supp 1 1. CLINICAL UPDATES.

8 Peripheral arterial disease Ischaemia BMJ: first published as on 16 November 2017. Downloaded from on 31 January 2022 by guest. Protected by copyright. Loss of protective sensation Unnoticed repetitive trauma Neuropathy Foot deformity/Joint rigidity Improper loading, abnormal plantar pressures ULCER. Dry skin and decreased integrity Cracks and fissures in skin Barefoot walking, improper footwear Lack of education to health providers Lack of education to patients Lack of foot protection service GANGRENE. Neuropathy Trauma Inflammatory reaction Infection Charcot foot (osteoarthropathy) Foot deformity AMPUTATION.

9 Fig 1 | Risk factors and mechanism for foot ulcer and amputation (fig 2). Look for lesions such as fungal infection, cracks pain, which suggest peripheral arterial and skin fissures, deformed nails, macerated web spaces, Palpate the posterior tibial artery and dorsalis pedis calluses, and deformities such as hammer toes, claw artery in both feet and record pulsations as absent or toes, and pes cavus, which increase the risk of ulceration (fig 3). Feel the temperature of the feet with the dorsum The ankle brachial index is an adjunct measure to of your hand.

10 A cold foot might suggest ischaemia, and diagnose peripheral arterial 21 It is the ratio of increased warmth with redness and swelling might the highest systolic blood pressure at the ankle (dorsalis suggest inflammation such as acute Charcot foot or pedis artery or posterior tibial artery) to the systolic cellulitis. blood pressure at the arm, and is measured using a Doppler See box 2 on grading the severity of Peripheral neuropathy obstruction. Measurement of the ankle brachial index The aim of screening is to identify patients with loss is user dependent.