Alarm Features starring the High Risk Diabetic Foot Sue Robb Podiatrist Foot Health Service West Hertfordshire Community Health Services in 5 minutes!?

The Diabetic Foot – when to refer QOF screening – Who is high risk? Alert!  refer to Foot Health Service Alarm !   urgent referral, & include Foot Health Service

Risk features of neuropathic foot Warm foot, well-perfused, bounding pulses, distended veins due to a-v shunting Sweating  skin dry/fissured Distal (below knee) symmetrical sensory loss Deformity, flexed toes, high arch, prominent met heads High pressure points  callus QOF points

Neuropathic ulceration Plantar metatarsal heads, apecies of toes High vertical pressures Ulcer covered/surrounded by callus, macerated by discharge Usually painless – pain first sign infected Good circulation – necrosis develops secondary to infection

Charcot arthropathy  Neuropathic osteoarthropathy - non infective destruction of bone  Affects patients with neuropathy  Acute phase mimics infection  Casting stabilisation / non- weight bearing essential  Weight bearing  ‘bag of bones’ appearance  ulcer from deformity

Neuroischaemic foot Atrophic thin frail shiny skin Diminished/absent foot pulses Pallor on elevation Rubor on dependency due to capillary dilatation Intermittent claudication / rest pain, yet may be pain free Unforgiving foot QOF points

Neuroischaemic ulceration Ulcers on margins of feet associated with trauma and fragile micro circulation Thin glassy callus or no callus First sign? - skin discolouration that blisters Pain may be due to infection or ischaemia

Identify high risk at screening High risk - presence of any risk factor for ulceration. Refer to FHS + continue screening Risk factors for ulceration are 1.Previous ulceration / amputation 2.Neuropathy 3.Absent/diminished pulses 4.Deformity / LJM 5.Callus 6.Oedema 7.Visual loss 8.Self neglect / disability Low current risk Foot care education + annual screening. No FHS ref No risk factors for ulceration = Low current risk Foot care education + annual screening. No FHS ref

Infection <Osteomyelitis Look for signs of response to t/t in 3 days callus Sausage shaped toes “Beef chipolatas” Probe to bone Pre ulcerative

Prevention of diabetic foot ulceration Good glycaemic control essential Education – improve foot care knowledge and behaviour Daily foot check Appropriate footwear Timely vascular intervention ‘High risk’ patients referred to Foot Health Service

‘Team’ working prevents problems Early recognition and referral of the ‘at risk’ foot Early detection and referral of ulceration, Charcot, severe infection, acute/critical ischaemia ‘Shared care’ programme – diabetes team, GP, nurse, podiatry and patient

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