Вы находитесь на странице: 1из 40

Diabetic Foot

Two main Complications of


Hyperglycemia

Ischemia
Neuropathy

Predisposing peripheral vascular disease


Atherosclerosis
(medium-sized vessels below the knee)

Compromised blood supply


Ischemia

Coagulative necrosis

Ulcer
Ischaemic toes due to
artherosclerosis

Infection

Dry gangrene

Wet gangrene

Neuropathy
Neuropathy

Sensory

Motor

Muscle wasting
Foot weakness
Postural deviation

nociception

Deformities, stress
and shear pressures

Trauma

Proprioception,
Unawareness
of foot position

Stress on bones & joints


Plantar pressure

Callus formation

Ulcer

Autonomic

Reduced
sweating

Dry skin

Fissures and
cracks

Infection

Activation of Protein Kinase C


Intracellular hyperglycaemia

Stimulates de novo synthesis for diacylglycerol (DAG)

Activates PKC

Downstream effects:
Production of vascular endothelial growth factor
Increased vasoconstriction
increased deposition of extracellular matrix and
basement membrane material
Production of plasminogen activator inhibitor
Production of proinflammatory cytokines

Disturbance in polyol pathway


Hyperglycemia

increase IC glucose
(eg: nerves, lens, kidney, blood vessels)

metabolize by aldose reductase

sorbitol (polyol)

Fructose
Accumulated sorbitol & fructose

Increase IC osmolarity

Influx of water

Osmotic cell injury

NADPH used up during polyol pathway

Decreased GSH (Reduced glutathione)

Cells susceptible to oxidative stress

Oxidative cell injury

Nerve Damage

Diffentiation of Ischaemic and


Neuropathy Ulcer
Ischaemia

Neuropathy

Symptoms

Claudication
Rest pain

Usually painless
Or painful neuropathy

Inspection

Dependent rubor
Trophic changes
Gangrenous digits

High arch + clawing of toes


No trophic changes
Surrounded by callus

Palpation

Cold
Pulseless

Warm
palpable pulses

Ulceration

Painful
At the distal and over
bony prominences

Painless
Sites of pressures
(metatarsal heads, heels)

Claw toe

Severe atrophy of the intrinsic foot muscles (lumbrical & interossei)


d/t motor neuropathy resulted in imbalance of foot muscles & cocked-up toes.

Neuropathic foot ulcer

Callus formation on its surrounding ulcer lesion.

Infection
Individuals with DM have a greater frequency and severity of
infection.
Reasons:
abnormalities in cell-mediated immunity and phagocyte
function
diminished vascularization
Hyperglycaemia aids the colonization and growth of a variety of
organisms (Candida and other fungal species).
Common pathogens:

Combined with local ischemia, insensitivity to skin injury and


localized pressure d/t deformity, more susceptible to infection

Clinical presentation of diabetic foot

Ischemic foot ulcer

Foot ulcers

Charcot Joint
Diabetic neuropathy is the most
common cause.
An acute Charcots foot will have
swelling, erythema, raised skin
temperature, joint effusion and
bone resorption in an insensate
foot

Charcot Joint

Rocker bottom charcot


foot

Dry Gangrene

Wet Gangrene

Gangrene
Gangrene is a condition that involves the death and decay of
tissue, usually in the extremities due to loss of blood supply.
Dry gangrene

Wet gangrene

no infection
little tissue liquefaction
In early stages, dull,
aching pain, extremely
painful to palpate, cold,
dry and wrinkled.
In later stages, skin
gradually changes in
color to

Bacterial infection
copious tissue
liquefaction
offensive odor
swollen, red and warm.
usually develops
rapidly due to blockage
of venous and/or
arterial blood flow

dark brown, then


dark purplish-blue, then
completely black

Treatment is surgical debridement and amputation.