THE DIABETIC FOOT Nicola Kilburn Diabetes Specialist Podiatrist
Diabetic foot disease is associated with significant morbidity and mortality. Foot screening is effective in identifying an individuals risk of developing a foot ulcer which may lead to amputation. People at low risk have a 99.6% chance of remaining free of ulceration at 1.7 years of follow up. Multidisciplinary foot teams improve the outcome of patients with active foot disease.
SIGN 116 All patients with diabetes should be screened to assess their risk of developing a foot ulcer. Results should be entered on online screening tool i.e. SCI-Diabetes. Gives accurate automatic risk stratification and management plan. Inaccurate risk stratification may be prone to medico-legal challenge.
Scottish Diabetes Action plan 2010 Within previous 15 months 80% of people with diabetes should have electronically recorded foot risk score. All patients with low risk feet should have access to education for self management. National foot care leaflets provided. IT links between national diabetes database and GP systems.
Putting Feet First - Diabetes UK A person who has had active foot disease has a 40% risk of a second episode within 12 months. Average life expectancy is reduced by 14 yrs. Major amputations-5yr survival rate of less than 50%. Cardiovascular risk predominant cause of mortality.
At Diagnosis Education to optimise foot care. Receive foot screening from an appropriately trained HCP Automatically stratified foot risk score on SCI Diabetes National leaflet given appropriate to risk score and contact numbers.
SCREENING ASSESSMENT Detects early Disease Establishes a diagnosis Involves tests that have predictive value and an agreed cut-off point for referral Involves clinical decision-making skills and clinical autonomy for onward referral Requires healthcare worker trained for competence in screening Requires a healthcare professional Does not involve a treatment plan Decides on a future treatment/management plan Patient does not influence outcome Patient may influence outcome It is a continuous process at predetermined time intervals Reassessment is patient-led depending on symptoms or response to therapy Adapted from article in DFJ 2006 Vol 9 No4 2006 by Maria Mousley
TRAFFIC LIGHTS
SCI DIABETES
RISK TRIANGLE 15% High risk Intensive foot protection 5% 15% 5% Active ulcers or Infection. Revascularisation or Amputation Multidisciplinary foot care team management 20% 20% Moderate risk Regular foot protection 60% Low risk Routine annual screening 60% The Pyramid of Foot Care for a population of people with Diabetes (Young 2006)
Active Foot Disease Refer to MDFC at presentation. Emergency-GG&C target is one working day-depends on patient availability and transport issues. May be shared care between community based podiatry services, community nurses, and MDFC. Pre-planned follow up with community based podiatry services once healed.
Risk Factors: Pathophysiological IMPORTANCE OF SCREENING FOR BOTH
Ischaemic Foot Cold Cyanotic/pale Absent pulses Dry, shiny skin Lack of hair Atrophied nails Intermittent Claudication Rest pain Ulcer slow healing, painful Gangrene Medial artery calcification General IHD, angina, CVA
Ischaemic Ulcers
Neuropathic Foot SENSORY NUMB LOSS OF PROTECTIVE SENSATION TINGLING/PINS AND NEEDLES SHOOTING PAINS AUTONOMIC Dry, warm, fissures A/V shunting, veins prominent, oedema Palpable/bounding pulses MOTOR High arch/claw toes Deformity/high pressures Callus/ulceration Infection,osteomyelitis
Neuropathic Foot
Neuropathic ulcers
Charcot Foot Non ulcerative pathology Conjunction with ulceration
Bony Destruction Changes can occur in 1 / 2 weeks Heat, redness, swelling, temp gradient, may be pain Rocker bottom sole deformity X-ray shows fragmentation, fracture, new bone formation and dislocation
PRESSURE RELIEF TCI(total contact insoles) TCC(plaster cast) Off loading devices for active foot disease,eg Aircast boot, forefoot/hind foot relief shoes Extra depth shoes Bespoke footwear
No Insole Peak Pressures > 500 KPa 81R 81L
Total Contact Insole Peak Pressures < 300 Kpa 20L 20R
Other Resources National Leaflets, leaflets (in various languages) www.diabetesinscotland.org.uk FRAME(Foot Risk Awareness & Management Education) www.diabetesframe.org SCI-DC DVD and Hand Book DVD is available at www.diabetesdvd.co.uk Local Specialist Diabetes Podiatrist Multi-disciplinary Diabetic Foot Clinic Expectations of foot care for people with Diabetes-MCN foot group