MCN Professional Conference 2017 The Diabetic foot Lorna Jarrett Advanced Diabetes Podiatrist

Session Content Overview of diabetic foot pathologies Risk factors / The at risk foot Charcot Foot Diabetic Foot screening Traffic Lights Triage & Referral Screening resources for HCPs Ulcers & Referral Patient Education Optional foot screen demonstration

Learning Outcomes Increased knowledge of diabetic foot pathologies Raised awareness of diabetic foot ulcer management/ prevention Awareness of the revised traffic light system/ referral & triage Training resources for HCPs Role of the Podiatrist and MDT in the diabetic foot

Scottish Foot Ulcer & Amputation Stats 13,440 people with type 1 or 2 diabetes recorded as having a foot ulcer ( 4.8%) 1 2,092 ( 0.7%) recoded as having a lower limb amputation 1 80 % of Diabetes amputations are thought to be preventable 2 Diabetes foot ulcers and amputations cost £ 64 – 66 Million per annum 3 1 . Scottish Diabetes Survey 2015 2. DUK 2015 3 . Kerr 2012

Four Types of Diabetic foot Normal Ischaemic Neuropathic Neuro ischaemic Most common type is Neuro – ischaemic

Risk factors for DFU PAD- peripheral arterial disease DPN – Diabetic Peripheral Neuropathy , sensory, motor and autonomic Previous ulceration Current ulceration Significant callus Unable to self care Social isolation Smoking Sub optimal diabetes control Excess alcohol consumption Inappropriate footwear Self treatment of corns & calluses

Risk Factors PAD -Macroangiopathy The blood vessels become atherosclerotic Vessels narrow and reduce blood flow Oxygen flow to tissues is compromised Can cause painful claudication, devitalised tissue and poor wound healing Pain is not always present in PAD as symptoms may be masked where neuropathy is present

Risk Factors PAD-Microangiopathy Small vessel disease Mottled ischaemic patches Devitalised tissue at risk of ulceration

Risk Factors -Sensory neuropathy Often asymptomatic Diminished pain perception Decreased vibratory sensation Impaired Proprioception Absent reflexes in lower limb Often asymptomatic and patient is unaware of any changes

Risk Factors -Motor neuropathy clawing of toes high plantar arch high pressure over metatarsal heads

Risk Factors -Autonomic Neuropathy A- V Shunting Bounding Pulses Pink skin – looks well perfused Dry non sweating skin Risk factor for Charcot foot

Aetiology of Charcot Foot Neuro traumatic theory This theory suggests that Charcot Foot results from repetitive micro trauma from weight bearing on an insensate foot, and that this trauma leads to intracapsular effusions, ligamentous laxity,fractures and joint instability. The absence of protective sensation allows continued loading of the fractured foot

Neuro vascular theory Autonomic neuropathy leads to changes in the normal vaso constriction & dilatation mechanism. Arterioles unable to constrict normally and remain abnormally dilated leading to an increase in blood flow to foot bones and an increase in osteoclastic activity. Bones become dematerialized, fragile and break easily It is thought that a combination of the 2 theories play a role in development of the Charcot foot

Clinical Presentation Red, hot, swollen foot Typically painless or only mildly painful unilateral swelling of extremity Can mimic cellulitis , gout, osteomyelitis and even DVT Plain films may appear normal initially Suspected Charcot needs urgent referral to MDT

Diabetic Foot Screening Cornerstone of good Diabetic Foot care Quick, simple and can be carried out by any suitably trained HCP Not a data collection exercise Assess patients risk level of developing an ulcer that may lead to amputation Referral and follow up based on risk level SCI – Diabetes Standardised screening across Scotland Automatic risk calculation Prevents duplication Secure shared information Onward referral as required

Why carry out foot screening To assess a patients risk of developing a foot problem that may lead to amputation Screening for all the known risk factors Then calculating the cumulative effect they have and working out the risk status Assign risk level Low Moderate High In Remission Active Foot Disease Risk levels linked to Traffic Light Diabetic Foot risk Stratification & Triage

What do we screen for? Peripheral arterial disease ( PAD) DPN – Diabetic Peripheral Neuropathy DPN) Previous ulceration Current ulceration Significant callus Unable to self care Previous amputation Significant structural abnormality

Neuropathy Screening 10g Monofilament Ask about neuropathic symptoms Pain, paraesthesia , Allodynia

Ask patient if they Suffer from symptoms of painful neuropathy i. e *Ask patient if they Suffer from symptoms of painful neuropathy i.e. Shooting pains, paraesthesia, Allodynia.

Screening resources for HCPs F R A M E Foot Risk Awareness and Management Education An interactive e learning resource featuring animations and case scenarios to ensure that screeners have the competence to do so. www.diabetesframe.org

Based on the Traffic Light foot risk stratification & triage system Referral & Management Based on the Traffic Light foot risk stratification & triage system

Referral Pathways Hospital Diabetes Foot Clinic Community podiatry

Why should you refer? Ulcer management is multidisciplinary Specialist diabetes foot teams Quicker healing times Amputation prevention Holistic care

DFU Management SIGN 55 recommends multidisciplinary team input Any hole in the foot refer to specialist clinic in Lothian as soon as possible Royal Infirmary Western General St Johns

DFU Management- More than just a dressing! Key Areas Debridement Off loading Infection Control Optimising Diabetes Control The care of the diabetic foot requires a MDT approach : podiatrists, physicians, nurses, orthotists, vascular & orthopaedic surgeons

Patient Education Daily Foot Check Avoid walking barefoot General advice Daily Foot Check Avoid walking barefoot Moisturise dry skin Don't self treat callus Corns Avoid direct heat Check bath water temp Wear suitable footwear If in doubt seek professional help

Final thoughts... Diabetes is a chronic condition. Foot problems are not always treated as seriously as they should be Underestimated of potential devastation by many Education of all health professionals Knowing when to refer AND how to refer foot problems Ultimately reducing amputations Feet are not very glamorous. Potential devastation is usually grossly underestimated by those outside a specialist team.

Thank you for listening Questions? Thank you for listening