Diabetic foot

                                                               Diabetic Foot:
Introduction

• From the time of insulin discovery, important observation was made by Joslin, who reported that, a large population of patients diagnosed to have diabetic mellitus, will develop foot ulceration or gangrene.
• Diabetic foot result from the way health provider look on the patients and the way patients look after themselves.
• Although this complication is the mostly feared by patient with diabetic, it is easly preventable through education and care.
• major complication from diabetic foot are lower limbs amputation.

What is Diabetic foot?

-Diabetic foot- are lesions occurring in people with diabetic mellitus, which range from superficial skin ulcer, infection of the ulcer to chronic bone infection/osteomylitis. 

-Diabetic foot can present in different ways, but the most important clinical presentation are foot ulcer.

- Diabetic Foot ulcer are sores in the feet occur in people with diabetic mellitus.

Epidemiology

-prevalance varying from place to place- in Europe is < 1%, but in Africa is around 11%, Tanzania is around 16% .

- diabetic foot in vast majority is associated with lower limbs amputation. About 28% to 51% of patient underwent first amputation, need second amputation within period of 5 years.

- mortality rate after amputation range from 39% to 68% after the lower limbs.

Risk factor for diabetic foot ulcer

• peripheral neuropathy
• peripheral arterial occlusive disease
• poor glycemic control
• obesity
• foot deformity 
• immune suppression 
• past history of ulcer/ amputation

Pathogenesis of diabetic foot ulcer

- for simple understand, its been divided into three parts

• Neuropathy-  is the disorder of nerve outside of brain and spinal cord, result from damage of peripheral nerve. Occur in 80% of all patients with diabetic foot ulcer. It can affect both sensory, motor and autonomic pathways. 

                  -motor neuropthay- affecting motor fibres/nerves to intrinsic muscles leading to atrophy                                                   from areas with increased pressure or friction from bones prominence.

                  

                  - autonomic neuropathy- lead to dermal/skin denervation of the affected area, which                                                                    results into reduced sweating, dry skin and eventually lead to the                                                            formation of fissure. It can also results into loss of sympathetic                                                              tone , which results into thickness of capillary basement                                                                          membrane, and loss of postural vasoconstriction, arterial-venous                                                            shunt and increased blood flow, predisposing to trivial skin                                                                    ulcer formation.

                - sensory neuropathy- vibration, temparature, and pain sensation is lost. Loss of awareness                                                      of pressure injury or trauma, can lead to unnoticed ulcer and                                                                  infections. 

• Diabetic foot angiopathy- peripheral arterial occlusive disease, is very common problem in diabetic patient. Diabetic foot angiopathy has been divide into microangiopathy and macroangiopathy. Occlusion of arterial, prevent oxygen, white blood cell and nutrients from reaching ulcer. This in turn affect the physiological process of wound healing.
• Immunopathy- immune cells function, chemotaxis ,phagocytosis and killing capability is loss.

Prevention of diabetic foot ulcer

• education and better health care.
• glycemic control to reduce neuropathy and maintain immune fuction
• patient self care, regular nail check, therapeutic shoes use, protecting self from lower extremities injury.
• regular assessment of  every diabetic patient limbs, early and proper management ulcer.

Management

- the management of diabetic foot ulcer involve three parts;

• removal of callus
• eradication of infections
• reduction of weight bearing forces often require bed rest with leg raised.

Danger signs: urgent treatment needed

- Redness and swelling of a foot that even when neuropathic causes

some discomfort and pain; this often indicates a developing abscess,

and urgent surgery may be needed to save the leg

- Cellulitis, discolouration, and crepitus (gas in soft tissues)

- Pink, painful, pulseless foot even without gangrene indicates critical

ischaemia that needs urgent arterial investigation followed by

surgical intervention whenever possible.

                                  BY MWANDA MD.