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The shearing forces during dynamic walking, in addition to the balance between the
forces of the pushing down of the body weight and the pushing up of the ground
reactive forces, create friction and compressive forces on the foot.Abnormalities in
foot biomechanics may result in a dysfunctional gait and can lead to structural
changes in the foot that increase the ri sk of ulceration and subsequent amputation.
Loss of sensation, especially at pressure points, may lead to persistent stress, which
may result in development of a bunion and subsequent skin breakdown and ulcer
formation. The deep aspect of the plantar apone urosis sends septa that divide the
plantar aspect of the foot into three major compartments: medial, central, and lateral
(Figure 2).
[(Figure 2). Schematic anatomic diagram of forefoot compartments. Deep soft tissue
infection is likely to spread along these compartments. Ô = central compartment; =
dorsal compartment; = lateral compartment; = medial compartment.]
These compartments contain the long flexor tendons and the tendons of intrinsic
muscles of the foot covered by synovial sheaths. Extensi on of infection into these
compartments might increase the intra compartmental pressure, which may further
interfere with the blood supply to the distal portions of the foot and thus exacerbate
the problem of ulceration and poor healing.
Every cell in the human body needs energy in order to function. The body¶s primary
energy source is glucose, a simple sugar resulting from the digestion of foods
containing carbohydrates (sugars and starches). Glucose from the digested food
circulates in the blood as a read y energy source for any cells that need it. Insulin is a
hormone or chemical produced by cells in the pancreas, an organ located behind the
stomach. Insulin bonds to a receptor site on the outside of cell and acts like a key to
open a doorway into the cell through which glucose can enter. Some of the glucose
can be converted to concentrated energy sources like glycogen or fatty acids and
saved for later use. When there is not enough insulin produced or when the doorway
no longer recognizes the insulin key, glucose stays in the blood rather entering the
cells.
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Diabetic foot is an umbrella term for foot problems in patients with diabetes mellitus.
It is better known as diabetic foot ulcer. Diabetic foot ulcer is one of the major
complications of Diabetes mellitus. It occurs in 15% of all patients with diabetes and
precedes 84% of all lower leg amputations.[1] Major increase in mortality among
diabetic patients, observed over the past 20 years is considered to be due to the
development of macro and micro vascular complications, including failure of the
wound healing process. Wound healing is a µmake-up¶ phenomenon for the portion of
tissue that gets destroyed in any open o r closed injury to the skin. Being a natural
phenomenon, wound healing is usually taken care of by the body¶s innate
mechanism of action that works reliably most of the time. Key feature of wound
healing is stepwise repair of lost extracellular matrix (ECM) that forms largest
component of dermal skin layer. Therefore controlled and accurate rebuilding
becomes essential to avoid under or over healing that may lead to various
abnormalities. But in some cases, certain disorders or physiological insult disturbs
wound healing process that otherwise goes very smoothly in an orderly manner.
Diabetes mellitus is one such metabolic disorder that impedes normal steps of
wound healing process. Many histopathological studies show prolonged
inflammatory phase in diabetic wounds, which causes delay in the formation of
mature granulation tissue and a parallel reduction in wound tensile strength
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IN BOOK IN CLIENT
Several risk factors increase a person with diabetes chances of developing
foot problems and diabetic infections in the legs and feet.
ë
#% #&
ë ' # Smoking any form of tobacco causes damage to the small
blood vessels in the feet and legs. This damage can disrupt the healing Not present
process and is a major risk factor for infections and amputations. The
importance of smoking cessation cannot be overemphasized.
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Diabetics are prone to foot ulcerations due to both neurologic and vascular
complications.
?eripheral neuropathy can cause altered or complete loss of sensation in the foot
and /or leg. Similar to the feeling of a "fat lip" after a dentist's anesthetic injection,
the diabetic with advanced neuropathy looses all sharp -dull discrimination. Any
cuts or trauma to the foot can go completely unnoticed for days or weeks in a
patient with neuropathy. It's not uncommon to have a patient with neuropathy tell
you that the ulcer "just appeared" when, in fact, the ulcer has been present for
quite some time. There is no known cure for neuropathy, but strict glucose control
has been shown to slow the progression of the neuropathy.
Charcot foot deformity occurs as a result of decreased sensation. ?eople with
"normal" feeling in their feet automatically determine when too much pressure is
being placed on an area of the foot. Once identified, our bodies instinctively shift
position to relieve this stress. A patient with advanced neuropathy looses this
important mechanism. As a result, tissue ischemia and necrosis m ay occur
leading to plantar ulcerations. Microfractures in the bones of the foot go unnoticed
and untreated, resulting in disfigurement, chronic swelling and additional bony
prominences.
Microvascular disease is a significant problem for diabetics and can lead to
ulcerations. It is well known that diabetes is called a small vessel disease. Most
of the problems caused by narrowing of the small arteries cannot be resolved
surgically. It is critical that diabetics maintain close control on their glucose level ,
maintain a good body weight and avoid smoking in an attempt to reduce the
onset of small vessel disease.
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Most experts use some variant of the classification system developed by Wagner
and most currently modified by Brodsky.
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0 At-risk foot, no ulceration ?atient education,
accommodative footwear,
regular clinical examination
1 Superficial ulceration, not Offloading with total contact cast
infected (TCC), walking brace, or special
footwear
3 Deep ulceration exposing Surgical debridement, wound
tendons or joints care, offloading, culture -specific
antibiotics
4 Extensive ulceration or Debridement or partial
abscess amputation, offloading, culture -
specific antibiotics
&$ "&& % #
A Not ischemic
B Ischemia without Non invasive vascular testing,
gangrene vascular consultation if
symptomatic
C ?artial (forefoot) gangrene Vascular consultation
D Complete foot gangrene Major extremity amputation,
vascular consultation
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#" # : Client is in the depth classification of 3 , grade 2 and the ischemia
classification of µA¶ according to the classification of Wagger.
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IN BOOK IN CLIENT
Early sign include:
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IN BOOK IN CLIENT
Medical evaluation should include a thorough history and physical
examination and may also include laboratory tests, x-ray studies of
circulation in the legs, and consultatio n with specialists.
,)&&
."&!# The doctor may order Doppler ultrasound to see the blood
flow through the arteries and veins in the lower extremities. The test is Done
not painful and involves the technician moving a non -invasive probe
over the blood vessels of the lower extremities.
.c# If the vascular surgeon determines that the patient has Not Done
poor circulation in the lower extremities, an angiogram may be
performed in preparation for surgery to improve circulation.
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The management of diabetic foot ulcers requires offloading the wound by using
appropriate therapeutic footwear, daily saline or similar dressings to provide a moist
wound environment, debridement when necessary, antibiotic therapy if osteomyelitis
or cellulitis is present, optimal control of blood glucose, and evaluation and correction
of peripheral arterial insufficiency.
There are two main steps in the medical management of the diabet ic foot¶:
CARE OF WOUND:
þ Blood glucose level should be controlled by use of insulin in the various forms.
This is needed to provide good wound healing and tissue regeneration.
þ In the absence of diabetes, an individual cellular immune response results in
prolonged macrophage activity in a moist environment. Increased moisture
may promote autolysis without increasing the risk of infec tion. In persons with
diabetes and other individuals with a compromised cellular immune response,
pooling of fluid may promote colonization leading to infection.
AM?UTATION:
#" #
The client is treated with Inj. Humulin N 10 Units Before breskfast and meals. She is
also on T. Metformin 1 gm HS. The management done for here is wound
debridement. She is now treated with oral antibiotics Inj Amoxicillin 500 m g BD, Inj
Amikacin 500mg BD. The wound in the right leg is treated with Ointment silver max
and neomin and wet dressing done TDS.
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IN BOOK IN CLIENT
This will including cellulitis, septic arthritis, abscess and sinus Not in client
tract formation, osteomyelitis, gangrene, and charcot foot
disease with attention to the differential diagnosis of various
pathologic findings.
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Follow the healthy eating plan that you and your doctor or dietitian
have worked out.
Check your blood glucose every day. Each time you check your
blood glucose, write the number in your record book.
Check your feet every day for cuts, blisters, sores, swelling, redness,
or sore toenails.
Don¶t smoke.
%%
! " #&%
Check your feet. Look at the tops and bottoms of your feet at the end of each day to
make sure you have no reddened areas, cuts, or scrapes that could become
infected.
Bathing and drying:
* Use warm (not hot) water to wash your feet. Then dry your feet carefully, especially
between the toes. Apply cream or lotion after your feet are dry to keep the skin soft
and free of dry skin.
* If your feet sweat a lot, keep them dry by dusting with talcum powder.
Toenail care:
* Cut your toenails carefully, cut or file your nails straight across and then use an
emery board to smooth the sharp corners. Do not cut the sides or the cuticles.
* Clean your nails carefully.
* If your nails are thick or ha rd to cut, ask your doctor's office for help.
Foot warmth:
* Wear cotton socks to bed if you need extra warmth for your feet.
* Avoid using hot water bottles or electric heaters to warm your feet. Because you
may not fully sense hot and cold with your f eet, you may burn your feet accidentally
and develop an infection.
* Avoid putting your feet where they could accidentally be burned; for example, on
hot sand at the beach, in hot bath water or whirlpools, or near a fireplace. Use
sunscreen on the tops of your feet.
Footwear:
* Take your shoes and socks off at each visit to your provider so that the doctor can
easily look at your feet.
* Wear shoes at all times, even in your house, at the beach or by a pool.
* Wear comfortable shoes that fit well. Change to a different pair of shoes at least
once during the day.
* Ask your doctor about specially made shoes, especially if you have foot problems.
* Avoid wearing new shoes for more than an hour a day until they are thoroughly
broken in.
* Avoid tight-fighting shoes, socks and hose.
* Wear clean socks and change them at least once a day.
In addition to these foot care guidelines, keeping your blood sugar and your blood
pressure close to normal helps prevent foot problems.