Diagnosis
- Overall, 20–40% of people with diabetes have neuropathy and 20–40% have peripheral vascular disease (PVD), which are secondary to poor blood glucose control and adverse arterial risk factors (such as smoking or dyslipidaemia)
- 5% of people with diabetes may develop a foot ulcer in any year, amputation rates 0.5% per year
- MDT should normally include a diabetologist, a surgeon with the relevant expertise in managing diabetic foot problems, a diabetes nurse specialist, a podiatrist and a tissue viability nurse
MDT should:
- Assess interventions to reduce risk of cardiovascular events, CKD or anaemia
- Assess response to medical or surgical treatment
- Assess the foot and need for specialist wound care
- Assess pain
- Assess vasculature
- Review treatment of any infection
- Determine need for interventions for prevention of Achilles tendon contracture
- Orthotic assessment
Investigation
Annual inspection and examination to include:
- Testing foot sensation with 10 g monofilament (max 10 sessions) or vibration (calibrated)
- Palpation of foot pulses
- Inspection for any foot deformity
- Inspection of footwear
Categorise as:
- Low current risk (normal sensation, palpable pulses)
- Increased risk (neuropathy or absent pulses or other risk factor)
- High risk (neuropathy or absent pulses plus deformity or skin changes or previous ulcer)
Ulcerated foot:
- Assess size of ulcer and signs of infection, gangrene, ischaemia, neuropathy
- X-ray to determine extent of foot problem, MRI if osteomyelitis suspected and X-ray not definitive
- Suspected diabetic foot infection: soft tissue from debrided base for culture
Management
Chronic Care
- Low risk: improve knowledge, encourage beneficial self-care
- Increased risk: refer to foot protection team (3-6 mth check), inspect feet and vascular assessment
- High risk: refer to foot protection team (1-3 mth check), inspect feet and vascular assessment
- Intensified foot education, specialist footwear/insoles, skin and nail care
- Ulcers: urgent (<24hrs) assessment by trained professional and ongoing care by MDT including podiatrists, orthotists and diabetic nurses
- Patients who would benefit from re-vascularisation should be referred promptly
- Charcot osteoarthropathy (Joint neuropathy) if red, deformity and warmth referred immediately to MDT for joint immobilisation (NB CMT is a hereditary neuromuscular condition)
Hospital Care
- Assess < 24 hrs of diabetic foot admission, named consultant responsible for overall care
- Refer to MDT < 24 hrs
- Acute Presentation Inspection: Neuropathy; Ischaemia; Ulceration; Inflammation and/or infection; Deformity; Charcot arthropathy
- Infection treatment per local guidelines, if mild offer PO with effect against Gram +ve
Ulcer Management
- Debridement, dressings and off-loading (device to stop pressure) by MDT only
- Ischaemia assessment: maybe associated with redness & pain if infected or gangrenous, hence examine peripheral pulses, tissue loss, as well as colour and temperature and ABPI where possible
NICE Source: CG10 Type 2 diabetes foot problems: Prevention and management of foot problems and CG119 Diabetic foot problems: Inpatient management of diabetic foot problems. Summary compiled by Dr D P Sheppard MBBS.