Diabetic foot

diabetic-footIn the world, every 30 seconds one leg amputation is done because of foot gangrene caused by diabetes; it is the estimation of the World Health Organization. Diabetic foot is one of the most serious complications of diabetes and in Serbia, the number of patients with such disease increases because there is not quality prevention and education of the diseased.

Diabetic foot is one of the numerous complications of diabetes and represents a set of bone and soft tissue changes on feet of the diabetic patients. It occurs as the consequence of neuropatia and ischemia (nerve disease and the lack of blood in feet because of the disease of leg arteries), which can be additionally complicated by infections. The less serious degree of neurovascular changes of lower extremities is without any clinical symptoms. If the process progresses, the patients suffer from coldness of feet, reducing muscle ability, distractions in sensibility and the appearance of diabetic ulcers. The appearances of ulcers (ulceration) on a foot, the occurrence of gangrene and consequence amputation, are important causes of mortality and disability of the persons who suffer from diabetes.  These complications represent great medical, social and economic problem and significantly reduce the quality of life to a diseased of diabetes.

Diabetes, with ulcerations on lower extremities which cannot easily heal, is the cause of more than a half of the amputations of lower extremities in the United States of America and in the risk group it is present at three percent of population. The risk of losing legs and arms in the group of diabetic patients is about one percent a year in the world. According to the estimations of the World Health Organization, it is done about one million amputations a year, and every thirty seconds and so called great amputation of lower extremities for the reason of foot gangrene caused by diabetes. The previous ulcer (or amputation) after cured diabetic foot on one leg makes a predisposition, at the persons with diabetes, for reappearing the ulcer on the same of the other foot.

Predispositions for a diabetic foot

The risk factors for development of this disease are:

  • Age of the diseased and the duration of diabetes over 10 years, with chronically bad regulation of sugar in blood (>10 mmol),
  • Atherosclerotic process with evident cardiovascular complications which characterize diabetes,
  • Diabetic angiopathy (vasculopathy),
  • Disorder of sensibility (polyneuropathy),
  • Influence of tobacco smoke,
  • Bad education about diabetes and feet care,
  • Wearing inappropriate shoes,
  • Deformities of bone-joint system,
  • Inappropriate loads on feet
  • Professional exposure of diabetic feet to coldness and vibrations,
  • Injury (trauma) of feet and/or lower extremities,
  • The presence of many risk factors in the same time increases the probability of most frequent appearance of clinical changes on feet.
  • Peripheral neuropathy with the loss of protective sensibility,
  • Changes caused by exposure to pressure (redness, callus , bleeding under callus, warts and other lesions of skin),
  • Bone deformities of feet ( expressed heads of metatarsal bones, toes, Latin- pes cavus, pes planus),
  • Peripheral vascular disease (weakened or absent pedal pulses),
  • Previous presence of ulceration or amputation (one or more fingers, parts of a foot, or one of the feet),
  • Pathological changes on nails (trophic changes, ingrown nails and fungal diseases).

Kinds of diabetic foot

Diabetic foot, according to the manifesting clinical image, can be divided into two types:

  1. Neuropathic foot in which neuropathy dominates while the circulation is still satisfactory.
  2. Neuro- ischemic foot, in which, besides neuropathy, there is also vasculopathy or insufficient circulation which, in the level of cells, results their necrosis and creation of wounds (ulceration) which slowly heal because of hypoxia.

Clinical image

Diabetic foot is clinically manifested by the following visible manifestations and symptoms:

  • Ulcer/ulcers, ulceration/ulcerations on skin (the most frequently of toes) with the infection or without it. The infection additionally complicates the condition in both types (kinds) of diabetic foot, because through the ulcerations formed on a foot (or other lesions like warts, necrosis etc.) “enters” polymicrobic infection which percutaneously and hematogenicly spreads and destroys soft tissue of the foot and its bones causing osteomyelitis. These polymicrobic infections are usually caused by microorganisms from the groups streptococcus, enterotoxin, s. aureus, enterobacteria ( for example Escherichia colli) and various anaerobes (for example from the group of clostridium)
  • Typical deformities of feet,
  • Chronic swelling of feet and lower legs
  • Ischemic changes in soft tissues of feet like paleness, dryness and furfur, and weak and often absent pulsation of arteries.
  • Necrosis and gangrene (dying of some parts of feet), which is often preceded by phlegmon. Destruction caused by cell necroses followed by phlegmon is the main cause of limited or mass dying of foot tissue and numerous partial or total amputations in neuropathic or neuro-ischemic feet.
  • Symptoms of peripheral neuropathy which manifest as hypostasis or hyperstasis, achyrosis of the skin of feet.
  • Symptoms of peripheral artery insufficiency. At most patients, as well as diabetic ones, the disease of atherosclerosis of lower extremities is followed by peripheral artery occlusive disease, which is asymptomatic, while at others the symptoms of ischemia develop. They are manifested as claudication , ischemic pain in rest, paleness of skin followed by cold feet, cramps or fatigue of main groups of muscles in one or both lower extremities which compromise walking and the length of “walking distance” (walked way until the intensive pain or cramps until the termination of claudication by resting). These symptoms increase until the moment when the walk is not possible nay more and are resolved by resting (being still, standing or sitting) after a couple of minutes.
  • Claudication (limping) in the minute is intermittent and appears during fast walking, walking uphill and climbing stairs.
  • Muscle atrophy of lower leg is a frequent phenomenon because of tibioperoneal occlusion caused by atherosclerotic changes on blood vessels, bad nutrition of muscles and limited and irregular walking because of strong claudication pains.

 Diagnosis

The diagnosis is made according to: facts from anamnesis (history of the diseases), physical examination and the whole set of laboratory, radiological and other examinations according to which it is possible to estimate the type and the weight of the changes. It is usually made on the primary level of health protection and according to the subject difficulties of the patient and standard feet examination.

History of disease and physical examination:

  • Anamnesis should give information about basic fact related to diabetes and to discover the presence of characteristic neurovascular symptoms.
  • Physical examination has a special significance for determining the condition of muscle- skeleton status, vascular status (skin temperature of lower leg and feet, quality of dorsal puls of feet, blood pressure) and neurological status (condition of sensibility and reflex) of lower legs and feet. By this examination it can be determined the presence of infections, anatomic anomalies, obtained deformities of feet, disorder of statics and loads with pathological pressures on some parts of feet, with the changes on skin and these places (callosity, blister, ulcerations and other lesions, changing of color, dry skin etc).
  • If it is necessary, during the physical examination, small surgical treatments of wounds are done (cleaning, cutting and removing the parts of tissue) by which it can be determined the seriousness of the wound (necrosis).

Prevention of diabetic foot

  • Treating a diabetic foot in an advanced phase is very complicated and only a doctor can decide about it. This is much more complicated than the preventing measures which can (or should, every day) do every diabetic patient.
  • Only early recognition and immediate treatment of the initial changes on feet can prevent the creation of diabetes foot. And by that, every diabetic patient should regard that the persons with damaged nerves of diabetes do not feel pain.
  • By everyday examining under good light, patients can notice on time the initial changes on their feet.
  • Everyday hygiene, washing feet with warm water and soap and after that obligatory drying, especially spaces between toes, protects the skin of feet from possible infections.
  • Every day (when necessary many times a day) apply on your feet hydrating non-perfumed creams (for example panthenol), which prevents drying of skin and maintains its elasticity.
  • A diabetic patient must not allow his/her nails to grow too much, nails should be cut regularly, transversally, not leaving sharp edges in the ends of the nails.
  • A diabetic patient should never walk barefoot. The socks he/she wears must be woolen or cotton, of the appropriate size, not too tight. Stockings are not recommended because they tighten lower legs and limit the flow of blood through diseased blood vessels. Shoes should be of soft skin, wide enough in the front part, not to be too tight, and to be warm enough in wintertime to protect feet from the effects of coldness.
  • A diabetic patient should not use hot water bottles, electric blankets and other heating devices to warm his/her feet, because of reduced sensibility and bad circulation, heat can cause burns.

A diabetic patient has to be cautious if during examination he/she notices blisters, cuticles, ingrown nails, callus, bunions, deformed joints or wounds on the foot (obligatory consultation with doctors. A diabetic patient should avoid using medical herbs and balms, when he/she notices a smallest wound on his/her feet you should immediately visit your doctor.