Curriculum(Vitae

A.(Personal(Iden5ty

B.(Educa5on&(Training(
(

C.(Organiza5on(

Early Detection and

Prevention of Diabetic Foot

Learning Objectives
Identify risk factors and strategies for early
detection of diabetic foot
Explain the pathophysiology and etiology of
diabetic foot

People with Diabetes

Increased risk of hospitalized and infection
Have a 15 % life time risk of developing foot ulcer
Have 15 40 fold higher risk of leg amputation

Every 30 seconds a lower limb lost caused by diabetes

85 % of amputations are preceded by foot ulcer
Early detection can prevent 40-85 % lower limb amputation

Frykberg RG, et al. J Foot Ankle Surg, 2000

IDF , International Working Group on Diabetic Foot 2007

15 %

Outcome

50 %

35 %
No
amputation
no amputation

Amputation
amputation

Death
death

(5) 12%

(3) 7%
Improved

(5) 12%
(19) 44%

Minor Amputation
Major Amputation

(11) 25%

Died
Self request
discharge

n = 43 patients
Em Yunir, Kyoto Foot Meeting 2012

Source:
Speaker Meeting
Kyoto Foot Meeting 2008

Pathophysiology of Diabetic Foot

Risk Factors of Diabetic Foot

Peripheral neuropathy
Peripheral vascular disease ( PAD )
Foot Deformities/ biomecanic
History of ulcer or amputation
Non suitable footwear
Lack of access to health care
services

Edmond M, 2006

Risk Factors

10/11/2015

Kyoto Foot Meeting 2010

Peripheral Neuropathy

1. Autonomic Neuropathy
2. Motor Neuropathy
3. Sensoric Neuropathy

Autonomic neuropathy
Decreased sweating

Dry skin

Decreased elasticity

Repetitive Shears &

Pressures

Callus/ Fissure

Ulcer

Sensoric neuropathy
Loss protective sensation
Decreased of pain threshold
Lack of temperature sensation and proprioseption

Ill fitting shoes

Thermal trauma by hot water
Thermal trauma in `bajaj`

Somatic Motor Neuropathy

kaki :

Small muscle
wasting/hypotrophy

foot deformities
bone prominent

Increased foot pressure

Ulcer

Peripheral Arterial Disease

Correlated with atherosclerosis

A1c 1 % 26 % PAD
More aggressive
Narrowing vessel lumen obstructive
Distal tissue necrosis

Macrocirculation
Fatty
Normal Streak

Plaque
Athero- Rupture/
Fibrous sclerotic Fissure &
Thrombosis
Plaque

Plaque

Myocardial
Infarction
Ischemic
Stroke
Critical
Leg
Ischemia

Clinically Silent
Angina, TIA`s, PAD
Increasing Age

Cardiovascul
ar Death

Diabetic Foot Examination

Assesment

Test

Significants Findings

Patients History

Interview

Previous foot ulceration

Previous amputation
Diabetic > 10 years
A1c > 7 %
Impaired vision
Neuropatic symptoms
Claudicatio

Assesment

Significant finding

Gross inspection

Hammartoes
Claw toes
Halux valgus

Deformity

Prominent MTP I

Hammer toes
Claw toes

Pes Cavus

Assesment

Significant finding

Gross inspection

Deformities, Corn, calluses, bunion

Callus with ulcer
Prominent metatarsal head

Callus (1)

Callus

Callus + ulkus

Assesment

Significant finding

Dermatologic examination

Dry skin
Absence of hair
Yellow or erythematous scale
Ulcer
Heal Ulcer

Assesment

Significant finding

Dermatologic examination

Interspace maseration
Moist
Uhealing ulceration

Assesment

Significant finding

Nail deformities

Yellow, thickened nail

Ingrowing nail edge
Long or sharp nail

Assesment Test

Significant finding

Screening for Semmes-Weinstein

neuropathy
monofilamen 10 gram

Lack of perseption at
one or more side

Assesment Test

Significant finding

Screening for
neuropathy

Negative of vibration
perception

Tuning fork 128 Hz

Assesment

Test

Significant finding

Vascular
Examination

Palpation of dorsalis
pedis and tibialis
posterior arteri
Ankle Brachial Index
( ABI )
Color doppler

Decrease or absent
pulse
ABI < 0.9 consistent
with PAD

Measurement of the AnkleBrachial Index (ABI).

Source: American Heart Association

Interpreting the Ankle-Brachial pressure Index ( ABI )

ABI
>1.2

Interpreting
Rigid or calcified vessels or both

0.9 1.1/1.2

Normal (or calcified)

<0.9

Ischaemia

<0.6

Severe ischaemia

Source: American Diabetes Association Cek nilai

ABI tertinggi versi ADA 2015

Clinical Manifestation
Grade 1

Grade 2

Grade 3

Grade 4

Grade 5

Grade 6

Normal

High risk
Deformity
Nail abnormality
Dry skin
Hypotrophy
muscle

Ulcus
Ulcus at plantar
Neuropathy
Callus
Muscle at the
bottom

Infection foot
Edema
Rash
Infection
Osteomyelitis
Systemic
symptoms

Necrosis/
gangren foot --,
cutis, subcutis
fascia, joint.

Irreversible
Extensive
necrosis, should
be treated with
amputation

Wagner Classification

5 Cornerstones of Foot Management

Foot
examination
Treatment
before ulcer

Appropriate
footwear

Classification
risk factors

Education

Prevention Program
Do:
1. Check and take a look your feet everyday
2. Always using footwear
3. Check your shoes before wearing

4. Wearing proper shoes

5. Buy shoes in afternoon
6. Always wearing cotton socks
7. Wash your feet with smooth soap, dry it
8. Clipping nail horizontally
9. Check your feet to health care professional
regularly
10. Use moisturizing lotion regularly

Summary
Diabetic foot is one of chronic complications of
diabetes
Pathophysiology of diabetic foot ias very complex
Slow healing process, risk for ulcus to be chronic
and high incidence of amputation
Holistic management is mandatory and involving
multidisciplines
Majority of ulcus or injury in diabetic foot can be
prevented with early detection and prevention at
high risk of foot

Skin (1)

Skin (2)

Bulu kaki yang menipis

Atrofi jaringan subkutan

Skin (3)

Ulkus
Warna kulit kaki kemerahan

Tinea ( jamur )
Bulla
hiperpigentasi

Skin (4)

Maserasi kulit pada

sela jari

Bullae (tangan)

Nail (1)
1. Structure :
- atrophy
- hypertrophy
- fragile

Kuku(2)

2. Change of color
3. Abnormality of nail growth
4. Infection

Nail Abnormalities

Swelling

Deformities

Halux valgus

Hammer toes
Claw toes

Pes Cavus

Case Studies

Clinical Features and Diagnosis?

Mention physical abnormalities on below

picture

Slide 46