Diabetes Education Forum 22 nd Jan 08 The Diabetic Foot Maria Haley – diabetes specialist podiatrist Monica Sutton – diabetes specialist nurse Nuala Creagh - diabetologist

Objectives of Diabetic Foot Education Forum Clinicians should be familiar with Classification of risk in the diabetic foot Care pathways according to risk Risk assessment The Sheffield foot assessment tool and Care Pathway Foot Care advice for people with Diabetes Diabetic foot problems in primary care referral criteria, initial management, infection Charcot arthropathy – acute and chronic features

Diabetic foot forum 22 nd Jan Preventative care for the Diabetic Foot: Classification of risk and Care Pathways – Nuala Creagh 7.35 The Sheffield Risk Assessment Tool and Care pathway – Maria Haley 7.55 Foot Care advice for people with Diabetes – Monica Sutton 8.15 Diabetic foot problems in primary care – Nuala Creagh 8.30 Discussion

Epidemiology of the diabetic foot Commonest cause of hospital bed occupancy Foot ulcers occur in ~ 15% diabetic patients >1% undergo amputation Lower limb amputations ↑ x 15 in diabetes > 50% require amputation of other limb

Causes of diabetic foot ulceration < 15% purely ischaemic Remainder ~ 50% neuropathic, ~ 50% neuroischaemic Neuropathy main initiating factor Associated with trauma and/or deformity Triad present in 60%

Neuropathic foot ulceration Typically occurs at sites of high pressure Metatarsal heads, plantar surface of hallux Apices of toes Between toes if footwear tight Heels, especially in inpatients Preceded by callus Complicated by infection May occur at other sites due to injury

Clinical Guidelines Type 2 DM – NICE 2004 At annual review examination of feet should include Testing of foot sensation using 10g monofilament or vibration Palpation of foot pulses Inspection for any foot deformity and footwear Classify foot risk as At low current risk At increased risk At high risk Ulcerated foot

Classification of risk in the diabetic foot Low current risk normal sensation, palpable pulses Increased risk neuropathy or absent pulses or other risk factor High risk neuropathy or absent pulses + deformity or skin changes (callus) or previous ulcer Foot care emergencies and foot ulcers new ulcer, swelling, discolouration

Foot care according to level of risk 1 Low current risk (normal sensation, palpable pulses) Agree a management plan including foot care education with each person Increased risk (neuropathy or absent pulses or other risk factor) Regular review, 3-6 monthly, by foot protection team At each review Inspect feet Consider need for vascular assessment Evaluate footwear Enhance footcare education ie regular podiatry and footcare advice

Foot care according to level of risk 2 High risk (neuropathy/absent pulses + deformity or skin changes or previous ulcer) arrange frequent review 1-3 monthly by foot protection team Inspect feet Consider need for vascular assessment Evaluate and ensure appropriate provision of Intensified foot care education Specialist foot wear and insoles Skin and nail care ie regular podiatry, footcare advice and orthotics referral

Foot care according to level of risk 3 Foot care emergencies and foot ulcers ( new ulcer, swelling, discolouration) Refer to multidisciplinary foot team within 24hrs Expect that team as a minimum to Investigate and treat vascular insufficiency Initiate and supervise wound management Use dressings and debridement as indicated Use systemic antibiotics for cellulitis or bone infection as indicated Ensure an effective means of distributing foot pressures including specialist footwear, orthotics and casts

Pathways of footcare in Sheffield – primary care Risk assessment at annual review by practice nurse/GP If not competent at risk assessment, request training + refer patient to podiatry for risk assessment Low current risk Basic footcare advice refer to podiatry for group education session or if unable to care for own feet Increased risk Inspect feet 3 – 6 monthly Enhance foot care education Refer podiatry High risk as increased risk + refer for assessment for special footwear

Diabetic foot problems in primary care Referral Criteria Initial management including infection Charcot Arthropathy Amputation

Foot care emergencies and foot ulcers – ‘refer to foot care team within 24 hours’ Primary care guidelines for referral to foot clinic diabetic foot ulcer/necrotic lesion callus with local infection nail pathology with ischaemia and infection suspected Charcot arthropathy undiagnosed foot problem in At Risk foot high risk feet for assessment for special footwear Emergency referral – same day review or admit Spreading cellulitis, abscess, wet gangrene

STH Foot clinics NGH Mon am 9am – 1pm Tues pm podiatry led Wed am podiatry led RHH Tues pm 1.30 – 5pm Mon am podiatry led Wed am podiatry led Thurs am podiatry led

Diabetic foot problems in primary care In all cases assess foot ? history of injury ? neuropathic, ischaemic, neuroischaemic For evidence of infection Nb. The combination of infection and ischaemia is dangerous and may cause rapid tissue loss

Initial management of diabetic foot ulcers Definition Full thickness break in skin below level of malleoli Start antibiotics if any evidence of infection Swab foot ulcer base after cleansing Dressing Non adherent, avoid adhesive tape in ischaemic feet Relieve pressure – avoid weight bearing if plantar Refer diabetic foot clinic within 24 hours

Diabetic foot problems - infection Spectrum from local infection to spreading life-threatening sepsis Infected ulcer Yellowy/grey base, discharge, odour Sinuses/ exposed tendon or bone Mild cellulitis (<3cm) Local erythema, warmth, swelling Severe cellulitis (>3cm)

Infecting organisms in diabetic foot infections Mild cellulitis – usually staphylococci/streptococci Deep infections/osteomyelitis – often mixed staphylococci/streptococci Gram negative bacilli, eg E Coli, Proteus anaerobes

Diabetic foot infections First line antibiotics in primary care Augmentin 625mg tds or Flucloxacillin 500mg qds If penicillin allergic Clindamycin 300mg qds – most effective but caution in frail/elderly Clarithromycin 500mg bd Cephalexin 500mg tds, unless h/o anaphylaxis with penicillin If deep ulcer/odour, consider metronidazole

Diabetic foot infection – important practice points Complicates ulcers, rapid tissue loss with ischaemia Low index of suspicion, detect and treat early Diabetes specialist podiatrists may request prescription of antibiotics in community Osteomyelitis frequently requires 3 months or more antibiotics Prolonged antibiotics may also be indicated in critical ischaemia/ deep foot ulcers

Diabetic foot infection - Osteomyelitis Complicates deep ulcers, often associated with cellulitis Present if bone exposed or can probe to bone Typical sausage toe appearance Bony pain and tenderness typical Usually diagnosed clinically or by serial xrays Treatment medical unless extensive tissue loss, septic arthritis, abscess

Callus Callus, particularly plantar, hallmark of neuropathic foot Callus may overly ulcer If uncomplicated callus, refer urgently to podiatry If evidence of local infection, start antibiotics and refer to foot clinic

Nail pathology Ingrowing, involuted toe nails – refer podiatry Antibiotics if local infection Nail pathology with infection and ischaemia – refer foot clinic Fungal infection of nails refer podiatry for debulking 3/12 course lamisil if spreading, painful, cosmetically unacceptable

Diabetic foot problems - blisters Caused by trauma, usually inadequate footwear/ failure to wear socks In neuropathic/neuroischaemic feet Show need to review footwear May lead to ulceration Leave intact if no evidence of infection If associated infection – cloudy fluid/local cellulitis Cover with dressing Antibiotics Refer urgently to foot clinic

Non infective causes of red toe/foot Acute Charcot arthropathy Ischaemia Neuroischaemic diabetic foot may not be cold Erythema more pronounced on dependency Gout Fracture If doubt re diagnosis in at risk foot refer to foot clinic

Charcot arthropathy Destructive arthropathy Complication of peripheral neuropathy Results in gross deformity and risk of ulcers Early immobilisation reduces extent of deformity

Charcot arthropathy – acute phase Presents with redness and swelling foot +/- leg, +/- pain May be history of minor injury May follow fracture or surgery mimics cellulitis, gout, osteomyelitis, DVT

Charcot arthropathy - management High index of suspicion – if red, warm, swollen neuropathic foot Immobilise –ie no weight bearing + refer next foot clinic Pamidronate infusion Continue immobilisation for ~ 6 months Plaster of Paris, aircast walker

Amputation Major amputation, below knee or above – usually in the critically ischaemic foot gangrene severe sepsis or severe ischaemic rest pain Neuropathy alone rare cause of major amputation Severe sepsis and foot unsalvagable Severely disrupted ankle of Charcot arthropathy

Amputation Minor amputation – of toe(s), transmetatarsal osteomyelitis complicating neuropathic ulceration For ischaemic ulceration/gangrene following revascularisation Autoamputation of dry gangrenous toes may occur

To conclude…. Practice points and pitfalls Neuropathic foot may be symptomless Need for diabetic foot risk assessment Neuropathic ulceration Callus may obscure underlying neuropathic ulcer Ischaemia neuroischaemic foot may not be cold Acute Charcot arthropathy suspect if warm, swollen neuropathic foot

To conclude… Practice points and pitfalls 2 Refer all new diabetic foot ulcers within 24 hours of presentation Infection Treat early, low index of suspicion especially if ischaemia Prolonged courses often necessary May need to prescribe at request of podiatrists