DIAGNOSIS and

MANAGEMENT
of DIABETIC FOOT

Introduction

Rule of 15
15% of people with diabetes develop ulcers
15% of ulcers develop osteomyelitis, and
15% of ulcers result in amputation

Prevalence and incidence of diabetes and

diabetic foot ulceration in England
England

Population 17
years or older

Per 100,000
population

51,220,237

40,897,315

79,846

Prevalence of diabetes

5,4%

2,208,455

4312

Incidence of diabetic foot

ulcers in people with
diabetes (1-4%)

2,5%

55,211

108

Details
Population

Prevalence of diabetic foot

ulcers in people with
diabetes (4-10%)

7%

154,592

302

Frequency of treatment outcomes of diabetic foot ulcers among study subjects.

DAMA Rsurg: discharged against medical advice because patient refused surgery
(amputation); DAMA FC: Discharged against medical advice because patient lack
fund for further treatment. BKA: Below knee amputation

Variabel
Usia (tahun)
< 40
40 59
60 79
80
Jenis kelamin
Laki-laki (%)
Perempuan (%)
Lama menderita DM
Baru terdiagnosis
< 1 year
1-5 years
5-10 years
> 10 years
Kadar Gula darah saat MRS
< 200 mg/dL
200 mg/dL
Rata-rata lama perawatan di RS (hari)

Hasil (n=120)
4 (3.33%)
78 (65%)
35 (29.17%)
3 (2.5%)
50 ( 41.6%)
70 (58.33%)
32 (26.7%)
12 (10%)
34 (28.3%)
32 (26.7%)
10(8.3%)
62
58
14.6 11.14

Penderita ulkus kaki diabetik dewasa yang dirawat inap di RSUD dr. Saiful
Anwar Malang selama Januari 2009 Desember 2010.

Amputation is NOT the end of story !!!!

Approx. half of this pts will have contralateral
amputation within 3 years, and
Half will die within 5 years.

Risk Factors

The Pathways to Foot Ulceration

Metabolic
control

Education
control

Vascular
control

Mechanical
control

Wound
control

Microbiological
control

(Tentolouris, 2010)

Diabetic Foot Ulcer Pain

Diabetic Foot Examination

Patient history

previous foot ulceration, previous amputation,

diabetes 10 years, A1C 7 %, impaired vision,
neuropathic symptoms, claudication.

Gross inspection

Corn, calluses, prominent

hammertoes, claw toes

Dermatologic examination

Dry skin, absence of hair, yellow or erythematous

scales
Yellow, thickened nails
Ingrown nail edges, long or sharp nails
Interspace maceration
Ulceration

metatarsal

heads,

Screening for neuropathy

Lack of perception at one or more sites
(monofilament 10 g; vibration Abnormal perception of vibration
perception threshold testing;
Vibration perception threshold > 25 volts
tuning fork 128 Hz)
Vascular examination
Absent pulses
(palpation of dorsalin pedis and ABI < 0.90, consisten with peripheral arterial disease
posterior tibialis pulses; ankle
brachial index ABI)
Biomechanical foot assessment
(plantarflexion/dorsiflexion of ankles and great toes, assessment ptss ability to see and
reach his or her feet, inspection of ptss shoes)

Screening Tools
Most widely used proven tool to
screen for sensory peripheral
neuropathy
The SWM is applied at 10 sites.
With the patients eyes closed, the
providers applies the SWM and asks
the pts to identify the correct foot
and location.
Semmes-Weinstein Monofilament (SWM)

NOTE : After being used on >10 pts/day, the SWM loses its accuracy and
requires a recovery period of 24 h.

Vascular Examination
The examiner should attempt to palpate the
dorsalis pedis and posterior tibial pulse.
The dorsalis pedis may be palpated most easily
with the examiners second and third finger pads
when patient dorsiflexes the foot.
The posterior tibial pulse is best detected when the foot is inverted.
ABI 95% sensitive and almost 100% spesific when compared to vascular
disease proven by angiography.
0.70 0.90 : mild PAD
0.40 0.69 : moderate PAD
< 0.40 : severe PAD

Ulcer Assessment and

Classificaion

Meggitt Wagner System

Grade 0
No open foot lesion

Grade 2
Extends to ligaments, tendon, joint
casule or deep fascia w/o abscess or
osteomyelitis

Grade 4
Forefoot gangrene

Grade 1
Superficial ulcers, partial or
full-thickness

Grade 3
Deep ulcer with abscess,
osteomyelitis or joint sepsis

Grade 5
Extensive gangrene

PEDIS System
Perfusion , Extent , Depth, Infection, Sensation

Faktor-faktor yang harus di kontrol pada

proses penyembuhan luka :
1.
2.
3.
4.
5.
6.

Kontrol
Kontrol
Kontrol
Kontrol
Kontrol
Kontrol

luka
mekanik
vaskular
infeksi
metabolik
edukasi

International Working Group on Diabetic Foot, 2007

KONTROL LUKA

Wound healing
process

Chronic Wound Healing

1

Luka kronis
Ulkus diabetes

2
3

Debridement
Removing necrotic tissue, foreign material, and
bacteria from an acute or chronic wound critical
step in allowing the wound to go through the normal
phases of healing in a timely fashion.

TIMING ???
Wet gangrene should be debrided immediately
and the leg should be revasularized as soon as
possible there-after.
Dry gangrene and no cellulitis
should be revascularized first (it takes 4-10
days after revasc to optimize blood flow).
Debride well-vascularized wounds immediately if
wet gangrene is present.

DEBRIDING

SKIN

DEBRIDING

SUBCUTANEOUS TISSUE

DEBRIDING

FASCIA, TENDON, and MUSCLE

DEBRIDING

BONE

Indikasi operasi

Jaringan nekrosis yang luas

Asending infection
Osteomielitis
Koreksi deformitas
Amputasi

KONTROL MEKANIK

Acute Condition
Absolute restriction on weight bearing
Crutches, wheelchair
Immobilization of foot splint, cast, removable
cast until hyperemia resolved
Continue immobilization 4-6 months until
quiescence (chronic)
Once quiescent, treat as chronic.

Prinsip :
mengurangi beban tekanan
pada daerah luka

Istirahat, bed-rest
Non-weight bearing
Ambulatory : walker, wheel-chair, crutches
Penggunaan sepatu khusus : disain insole, half shoes
Casting : mendistribusikan beban berat badan secara
merata pada seluruh permukaan kaki

Cashting

Half shoe

KONTROL INFEKSI

Clinical manifestations, classification, and

treatment planning
Uninfected ulcers do not require antibiotic therapy
Mild infection : only skin and supereficial subcutaneous
tissue (any erythema 2 cm from the ulcer margin, and
any necrosis is minimal)

Can be treated on
ambulatory basis, and
follow antibiotic therapy
(semisynthetic penicillins, or first-generation cephalosporin)

 Moderate infections : erythema

extends 2 cm beyond the ulcer
border or ulcers in which infection
breaches the superficial fascia and so
involves deeper structure (tendon,
bone, joint).
need urgent empiric antibiotic therapy broad
spectrum coverage (gram positive cocci, aerobic
gram-negative rods and anaerobic)

 Severe infections : similar to moderate ones in anatomic

extent, but the patient manifests a systemic inflammatory
response (fever, leukocytosis, hypotension, or marked
meatbolic derangement)

Should be treated urgently, with initial hospitalization

and intravenous antibiotics (should cover organism
such as Pseudomonas aueruginosa).
Always considert the potential need for surgery.

Tehnik pengambilan sampel pus

Lakukan nekrotomi
Dan pembersihan luka
Buang jaringan nekrosis
semaksimal mungkin

Masukan hasil Swab

ke dalam media transport
Segera kirim ke laboratorium
Cuci dengan NaCl 0,9 %
Lakukan Swab pada daerah
luka, Terutama bagian dalam

Kontrol Metabolik
HIPERGLIKEMIA :
akan menghambat proses penyembuhan luka
menghambat growth factor, sintesis kolagen, aktivitas
fibroblas
Gangguan migrasi leukosit, fagositosis dan aktivitas anti
bakteri
Perbaiki kondisi yang menyertai (hipoalbuminemia,
hipertensi, penurunan
fungsi jantung dan ginjal,
dislipidemia, anemia, gangguan keseimbangan elektrolit,
dan penyakit penyerta lainnya)

KONTROL EDUKASI

Perawatan kaki diabetes

ThaNk YoU

HAEMOSTASIS

INFLAMMATION
Damaged vessels constrict
to slow blood flow
Platelets aggregate to stop
Bleeding
Leucocyte migrate into
tissue to initiate Iinflam. process

Neutrophils secrete chemicals to kill

bacteria
Macrophages engulf and digest foreign
particles and necrotic debris
Macrophages release angiogenic
substances to stimulate capillary
growth and the granulation process

PROLIFERATION

REMODELLING

Fibroblasts secrete collagen to strengthen

wound
Wound remodelling occurs to reorganise
fibers
Wound contracts increasing tissue integrity
Epidermal cells grow over connective tissues
to close wound

Fibroblast proliferate in the wound and

secrete glycoproteins and collagen
Epidermal cells migrate from the wound
edge
Granulation tissue is formed from
macrophages, fibroblasts, and new capillaries

Prevalence and incidence of diabetes and

diabetic foot ulceration in England
England

Population 17
years or older

Per 100,000
population

51,220,237

40,897,315

79,846

Prevalence of diabetes

5,4%

2,208,455

4312

Incidence of diabetic foot

ulcers in people with
diabetes (1-4%)

2,5%

55,211

108

Details
Population

Prevalence of diabetic foot

ulcers in people with
diabetes (4-10%)

7%

154,592

302

Variabel
Usia (tahun)
< 40
40 59
60 79
80
Jenis kelamin
Laki-laki (%)
Perempuan (%)
Lama menderita DM
Baru terdiagnosis
< 1 year
1-5 years
5-10 years
> 10 years
Kadar Gula darah saat MRS
< 200 mg/dL
200 mg/dL
Rata-rata lama perawatan di RS (hari)

Hasil (n=120)
4 (3.33%)
78 (65%)
35 (29.17%)
3 (2.5%)
50 ( 41.6%)
70 (58.33%)
32 (26.7%)
12 (10%)
34 (28.3%)
32 (26.7%)
10(8.3%)
62
58
14.6 11.14

Penderita ulkus kaki diabetik dewasa yang dirawat inap di RSUD dr. Saiful
Anwar Malang selama Januari 2009 Desember 2010.