1. Diabetes Mellitus Foot Syndrome Clinical features
OKONYIA NOSARIEMEN LILIAN
SENIOR REGISTRAR, EDM UNIT, LUTH

2. OUTLINE Introduction Clinical features -History -Examination Grading
Diff. diagnosis

3. INTRODUCTION
diabetic foot - exhibits any pathology that results directly from DM or any of its chronic complications.
DMFS- different aetiologies, diabetic foot pathologies, clinical picture
The most serious foot complications in diabetes
-Ischaemia
-Infection
-Neuropathic osteoarthropathy
Umbrella termCommon to all: foot injury in DMFS can result in complications that may lead to amputation if treatment is delayed or ineffective.

4. INTRODUCTION Evaluated at these levels: Individual Lower limb/foot
Ulcer

5. HISTORY Ulcer Location, duration Healing progression
Constitutional symptoms, Infection severity
Precipitants- trauma, boil, fissures, pedicure, tinea pedis
Inappropriate footwear, Bare foot walking
DM History
Duration of DM
Glycaemic control
-Infection is diagnosed by the presence of signs and/or symptoms of inflammation, but these may be blunted by neuropathy or ischemia,
-systemic findings (e.g. fever, increased white blood count) are often absent.
-Infections should be classified as mild (superficial with minimal cellulitis), moderate (deeper or more extensive), or severe (accompanied by systemic signs of sepsis).

6. HISTORY Past history Vascular symptoms ulceration amputation
Charcot joint
vascular surgery, angioplasty
cigarette smoking
Neuropathic symptoms
Positive
negative
claudication
rest pain
Non healing ulcer
Other diabetes complications:
-Macrovascular
-Microvascular
positive (e.g., burning shooting pain, electrical or sharp sensations, etc.)
negative (e.g., numbness, feet feel dead)
-many diabetic patients who undergo a lower extremity amputation have a very poor quality of life and have a 5-year mortality rate similar to that of some of the most deadly cancers
-Also called Charcot joint or neuropathic joint, Charcot arthropathy is a progressive condition of the musculoskeletal system that is characterized by joint dislocations, pathologic fractures, and debilitating deformities. This disorder results in progressive destruction of bone and soft tissues at weight-bearing joints; in its most severe form, it may cause significant disruption of the bony architecture. Charcot arthropathy can occur at any joint; however, it occurs most commonly in the lower extremity, at the foot and ankle.

7. PHYSICAL EXAMINATION General appearance ± Ill-looking Hydration status
fever
Regional lymphadenopathy
Anthropometry
-weight, Height
-BMI
-WC, W/H ratio

8. PHYSICAL EXAMINATION Ulcer exam Derma. exam Location Size Depth Base
Edge
Infection, Discharge, sinus
Skin appearance
Oedema
Cellulitis
Nail appearance
Fissures
Inter-digital areas
Gangrene
skin status: color, thickness, dryness, cracking, sweating,
calluses/blistering:
-deformity, e.g., claw toes, prominent metatarsal heads, Charcot joint

9. PHYSICAL EXAMINATION

10. DIFFERENCE BETWEEN NEUROPATHIC & ISCHEMIC ULCER

11. PHYSICAL EXAMINATION CVS/Vascular exam Peripheral pulses
-Dorsalis pedis pulse
-Posterior tibial pulse
ABI: Ankle systolic BP
Brachial systolic BP BP
Heart sounds
-The ankle-brachial index (ABI) is an efficient tool for objectively documenting the presence of lower-extremity peripheral arterial disease (PAD)
-Interpretation
> Poorly compressible vessels, arterial calcification
0.90– Normal
0.60– Mild arterial obstruction
0.40– Moderate obstruction
< Severe Obstruction

12. ABI CLASSIFICATION ≥1.30 Poorly compressible, arterial calcification
1-1.29
Normal range
Borderline Normal
Slight/Mild occlusion or Stenosis
Moderate occlusion or Stenosis
<0.40
Severe occlusion or stenosis

13. PHYSICAL EXAMINATION Neurological Exam Sensory exam
Joint position sense
Vibration sense (128Hz)
Light touch
Two point discrimination
Deep touch/Pressure
Motor exam
DTR-Achilles tendon
Abnormal gait
A reduction in the ankle jerk reflex may also be indicative of peripheral neuropathy.

14. PHYSICAL EXAMINATION Structural deformities: -Hammer toes -Claw toes
MSS exam
Structural deformities:
-Hammer toes
-Claw toes
-Charcot deformity
Small muscle atrophy
Limited joint movement
Prior amputation
Probe to bone test
muscle wasting (guttering between metatarsals)
-Also called Charcot joint or neuropathic joint, Charcot arthropathy is a progressive condition of the musculoskeletal system that is characterized by joint dislocations, pathologic fractures, and debilitating deformities. This disorder results in progressive destruction of bone and soft tissues at weight-bearing joints; in its most severe form, it may cause significant disruption of the bony architecture. Charcot arthropathy can occur at any joint; however, it occurs most commonly in the lower extremity, at the foot and ankle.

15. Probe to bone test
probing to the bone. A sterile metal probe is inserted into the ulcer if it penetrates to the bone it almost confirms the diagnosis of osteomyelitis. Chronic discharging sinus and sausage-like appearance of the toe are the clinical markers of osteomyelitis. Definitive diagnosis requires obtaining a bone biopsy for microbial culture and histopathology.

16. Harris Mat
-One of the best and simple tool to measure the plantar pressure. • Measures patient weight disbursement 
-helps to easily identify potential points of ulceration for diabetic individuals. 

17. FOOT DEFORMITIES
It is crucial to identify the presence of Charcot neuroarthropathy as this is likely to go unnoticed by the patient until a grossly deformed insensitive foot results, which is at an increased risk of ulceration (Figure 1). During the acute stage, the affected foot is swollen with pain or discomfort. On examination, the foot is warm, with a temperature differential of >2°C in comparison to the contralateral foot and may appear inflamed and swollen. The temperature of the overlying skin can be measured with an infrared thermometer and may be helpful in monitoring the disease activity of an acute Charcot foot.30 Acute Charcot foot may be misdiagnosed as cellulitis, osteomyelitis, inflammatory arhropathy or deep vein thrombosis.31 Therefore, a high index of suspicion is necessary so as to allow early identification and appropriate treatment of the acute Charcot foot. Once the acute phase of Charcot's subsides, which may take several months; the foot enters a chronic stage. The chronic Charcot foot is painless and deformed, without a temperature differential. The mid-foot is commonly involved in Charcot's neuroarthropathy and can result in mid-foot collapse with a plantar bony prominence and rocker bottom foot. This is associated with a significantly increased risk of ulceration.1

18. DMFS GRADING SYSTEMS Aims Facilitate appropriate Rx
Monitor response to Rx
Prognosis
Serves as form of communication

19. DMFS GRADING/SCORING SYSTEMS
Wagner
IWGDF (PEDIS) and IDSA.
S(AD)/SAD
University of Texas (UT) ulcer classification
SINBAD ulcer classification
Ulcer Severity Index (USS)
Diabetic Ulcer Severity Score (DUSS) and MAID
DFI Wound Score
IWGDF (PEDIS) and IDSA.
-clear definitions
-relatively small number of categories,
-more user-friendly
-the IDSA classification has been prospectively validated as predicting the need for and for limb amputation
Wagner
-the first, and still among the most widely used, classification schemes
-assesses ulcer depth and the presence of infection and gangrene
-The system only deals explicitly with infections of all types (deep wound abscess, joint sepsis, or osteomyelitis) in grade 3.

20. WAGNER GRADING OF DMFS

21. WAGNER GRADING

22. DMFS GRADING/SCORING SYSTEMS

23. PEDIS classification system.
Grade
Perfussion
Extent
Depth
Infection
Sensation
Score 1
No PAD
Skin Intact
Skin intact
None
No Loss 2
PAD, No CLI
<1cm2
Superficial
Surface
Loss 3
CLI
1-3cm2
Fascia, muscle, tendon
Abscess, Fascitis, Septic athritis 4
>3cm2
Bone or joint
SIRS

24. DIFFERENTIAL DIAGNOSIS
Tuberculous ulcer
Syphilitic ulcer
Sickle cell ulcer
Marjolins ulcer
Madura foot
Cutaneous leishmaniasis

25. SUMMARY/CONCLUSION Clinical presentation and grading of DMFS
Identifying these features of great value in prevention and management of DMFS

26. REFERENCES
Lipsky BA, Berendt AR, Cornia PB, Pile JC, Edgar Peters E, Armstrong DG Infectious Diseases Society of America Clinical Practice Guideline for the Diagnosis and Treatment of Diabetic Foot Infections. 2012;54(12):132–173.
Bakker K, Apelqvist J, Lipsky BA, Van Netten JJ, Schaper NC, the International Working Group on the Diabetic Foot (IWGDF). Prevention and management of foot problems in diabetes: a Summary Guidance for daily practice 2015, based on the IWGDF Guidance documents.