1. Diabetic foot Thongchai Pratipanawatr MD.

2. Site of Diabetic foot ulcers Site% Toe51 Plantar metatatarsal and mid foot 28 Dorsum of foot14 Multiple ulcers7

3. Outcome of Diabetic foot ulcers Outcome% Reepithelization/primary healing 63 Amputation24 Death13

4. Diabetic foot ulcer Neuropathic foot ulcer Ishemic foot ulcer Mixed ishemic-neuropathic

5. Neuropathic foot ulcer

6. Risk factors of foot ulcers Diabetic neuropathy increases risk of foot ulcer and amputation. Neuropathy1.7-folds Deformity12-folds Previous history of ulcer 36-fold

7. Distal sensory neuropathy Loss pain, temperature And fine touch sensation burning sensation Vibration, Position sense, Touch/pressure Motor: intrinsic muscle Small fiber Large fiber

8. Distal sensory neuropathy Diagnosis 10 gm monofilament: small fiber 128 Hz tuning fork: large fiber Motor deformity: large fiber

9. Sensory neuropathy Loss of protective sensation 5.07 (10 gram) Monofilament

10. Area of examination

11. Deformity Abnormal Foot pressure

12. Deformity Claw toes

13. Neuropathic foot ulcer Loss of sensation Deformity Callous formation Callous rupture Foot ulcer Infection

14. Diabetic foot ulcer Insensitive foot Inappropriate shoe (too tight) Deformity Ischemic foot ulcer

15. Insensitive foot

17. Insensitive foot examination ExaminationJustification GeneralInspect for possible ulceration SensoryTest sensation TemperatureLocal temp increase more than 2 C indicates of infection ShoesInspect foot ware MuscleMuscle deformaty

18. Neuropathic foot ulcer Loss of sensation Deformity Callous formation Callous rupture Foot ulcer Infection

19. Claw toes Deformity

20. Hammer toes Deformity

21. 21 Callous

22. 22 Ulcer

23. Chronic ulcer with osteomyelitis Osteolyticbone

24. Charcot’s foot

25. Acute Charcot’s foot Chronic Charcot’s foot

26. Charcot’s foot

27. Chacort’s deformity

28. Others neuropathic ulcer

29. Too tight shoe

35. Ishemic foot ulcer

36. Ischemic foot ulcer

39. Diabetic foot care

40. Risk factors of foot ulcers Diabetic neuropathy increases risk of foot ulcer and amputation. Neuropathy1.7-folds Deformity12-folds Previous history of ulcer 36-fold

41. Management category RiskSensationDeformityHx of ulcer 0PresentNo 1absentNo 2absentYesNo 3absentYes

42. Management category RiskManagment 0Foot clinic one a year; foot education 1Foot clinic every 6 months, appropriated footwear and soft insole 2Foot clinic every 3 months, custom- molded orthotic devices 3Foot clinic every 1-2 months, custom- molded orthotic devices

43. Foot education

44. Daily cleaning  

45. Skin & nail care

46. 46 ผิวแห้ง - แตก

47. Appropriated footwear and soft insole

48. Proper shoes design

49. Proper shoes &soft insole

50. เลือกรองเท้าที่เหมาะสมกับเท้าไม่คับหรือหลวมจนเกินไป

51. รองเท้าที่ไม่เหมาะสมกับเท้า

52. Custom-molded orthotic devices

53. Soft inserts

54. Mold insoles

55. Total contact insole

56. Foot wear

57. 57 Callous

58. 58 Callous

59. Diabetic wound care

60. Depth-ischemia classification GradeDefinition 0At risk (previous ulcer or neuropathy with deformity 1Superficial ulcer, no infection 2Deep ulceration exposing tendon or joint (with or without infection) 3Extensive ulceration with expose bone or deep infections Depth classification

61. Depth-ischemia classification

62. GradeDefinition ANot ischemia BIschemia without gangrene CPartial (forefoot) gangrene of the foot DComplete foot gangrene Ischemia classification

63. Depth-ischemia classification

64. GradeDefinition 0At risk (previous ulcer or neuropathy with deformity 1Superficial ulcer, no infection 2Deep ulceration exposing tendon or joint (with or without infection) 3Extensive ulceration with expose bone or deep infections Depth classification

65. Depth-ischemia classification GradeIntervension 0Patient education and appropriated foot ware 1External pressure relief 2And surgical debridement (antibiotic) 3And antibiotic; amputaiton may be Depth classification

66. Off-loading Total contact cast (TCC) -gold standard Prefabricated pneumatic walking brace ( Air cast ) Half-shoes Crutches,Walkers and Wheelchairs Bed rest

67. Total contact cast

68. Air cast

69. Half shoe

70. Modified/custom shoes/orthoses

71. Surgical intervenion Debridement Amputation Osteotomy Bone stabilization Tendon tranfer or Tenotomy Achilles tendon lengthening tendon etc.

72. Depth-ischemia classification GradeDefinition ANot ischemia BIschemia without gangrene CPartial (forefoot) gangrene of the foot DComplete foot gangrene Ischemia classification

73. Vascular screening ♦ Hair loss ♦ Color ♦ Baked potato skin ♦ Capillary filling time ♦ Temperature ♦ Pulses ♦ Ankle brachial index (ABI)

74. Thank you