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Diabetic foot Thongchai Pratipanawatr MD. Site of Diabetic foot ulcers Site % Toe 51 Plantar metatatarsal and mid foot Dorsum of foot 28 Multiple ulcers 7 14 Outcome of Diabetic foot ulcers Outcome % Reepithelization/primary healing Amputation 63 Death 13 24 Diabetic foot ulcer Neuropathic foot ulcer Ishemic foot ulcer Mixed ishemic-neuropathic Neuropathic foot ulcer Risk factors of foot ulcers Diabetic neuropathy increases risk of foot ulcer and amputation. Neuropathy 1.7-folds Deformity 12-folds Previous history of ulcer 36-fold Distal sensory neuropathy Large fiber Vibration, Position sense, Touch/pressure Motor: intrinsic muscle Loss pain, temperature And fine touch sensation burning sensation Small fiber Distal sensory neuropathy Diagnosis 10 gm monofilament: small fiber 128 Hz tuning fork: large fiber Motor deformity: large fiber Sensory neuropathy Loss of protective sensation 5.07 (10 gram) Monofilament Area of examination Deformity Abnormal Foot pressure Deformity Claw toes Neuropathic foot ulcer Loss of sensation Deformity Callous formation Callous rupture Foot ulcer Infection Diabetic foot ulcer Insensitive foot Inappropriate shoe (too tight) Deformity Ischemic foot ulcer Insensitive foot Insensitive foot Insensitive foot examination Examination Justification General Inspect for possible ulceration Sensory Test sensation Temperature Local temp increase more than 2 C indicates of infection Shoes Inspect foot ware Muscle Muscle deformaty Neuropathic foot ulcer Loss of sensation Deformity Callous formation Callous rupture Foot ulcer Infection Deformity Claw toes Deformity Hammer toes Callous 21 Ulcer 22 Chronic ulcer with osteomyelitis Osteolytic bone Charcot’s foot Charcot’s foot Acute Charcot’s foot Chronic Charcot’s foot Charcot’s foot Chacort’s deformity Others neuropathic ulcer Too tight shoe Too tight shoe Too tight shoe Too tight shoe Too tight shoe Too tight shoe Ishemic foot ulcer Ischemic foot ulcer Ischemic foot ulcer Ischemic foot ulcer Diabetic foot care Risk factors of foot ulcers Diabetic neuropathy increases risk of foot ulcer and amputation. Neuropathy 1.7-folds Deformity 12-folds Previous history of ulcer 36-fold Management category Risk Sensation Deformity Hx of ulcer 0 Present No No 1 absent No No 2 absent Yes No 3 absent Yes Yes Management category Risk Managment 0 Foot clinic one a year; foot education 1 Foot clinic every 6 months, appropriated footwear and soft insole 2 Foot clinic every 3 months, custommolded orthotic devices 3 Foot clinic every 1-2 months, custommolded orthotic devices Foot education Daily cleaning Skin & nail care ผิวแห้ง-แตก 46 Appropriated footwear and soft insole Proper shoes design Proper shoes &soft insole เลือกรองเท้าที่เหมาะสมกับเท้า ไม่คบั หรือหลวมจนเกินไป รองเท้าที่ไม่เหมาะสมกับเท้า Custom-molded orthotic devices Soft inserts Mold insoles Total contact insole Foot wear Callous 57 Callous 58 Diabetic wound care Depth-ischemia classification Depth classification Grade Definition 0 1 At risk (previous ulcer or neuropathy with deformity Superficial ulcer, no infection 2 Deep ulceration exposing tendon or joint (with or without infection) 3 Extensive ulceration with expose bone or deep infections Depth-ischemia classification Depth-ischemia classification Ischemia classification Grade Definition A Not ischemia B Ischemia without gangrene C Partial (forefoot) gangrene of the foot D Complete foot gangrene Depth-ischemia classification Depth-ischemia classification Depth classification Grade Definition 0 1 At risk (previous ulcer or neuropathy with deformity Superficial ulcer, no infection 2 Deep ulceration exposing tendon or joint (with or without infection) 3 Extensive ulceration with expose bone or deep infections Depth-ischemia classification Depth classification Grade Intervension 0 1 Patient education and appropriated foot ware External pressure relief 2 And surgical debridement (antibiotic) 3 And antibiotic; amputaiton may be Off-loading Total contact cast (TCC) -gold standard Prefabricated pneumatic walking brace ( Air cast ) Half-shoes Crutches,Walkers and Wheelchairs Bed rest Total contact cast Air cast Half shoe Modified/custom shoes/orthoses Surgical intervenion Debridement Amputation Osteotomy Bone stabilization Tendon tranfer or Tenotomy Achilles tendon lengthening tendon etc. Depth-ischemia classification Ischemia classification Grade Definition A Not ischemia B Ischemia without gangrene C Partial (forefoot) gangrene of the foot D Complete foot gangrene Vascular screening Hair loss ♦ Color ♦ Baked potato skin ♦ Capillary filling time ♦ Temperature ♦ Pulses ♦ Ankle brachial index (ABI) ♦ Thank you
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