DIABE
TIC
Foot
ULCER
Yandriyane Stephanie Robiady
131621190504
Diabetic foot
ulcer (DFU)
The presence of infection, ulceration and/or
destruction of deep tissues associated with
neurologic abnormalities and various degrees of
peripheral arterial disease (PAD) in the lower limb
in patients with diabetes.
The most frequent complication from Diabetes
Mellitus type 2
EPIDEMIOLOGY
1. 4-10% in the general diabetic population
2. 60-80% will heal, 10-15% will remain active, 5-24%
of infected limbs are amputated
3. DFU prevalence varies 1% in Europe, 11% in Africa.
4. DFU & amputation is still common in developing
country
ETIOLO
GY
1 2 3
PERIPHER PERIPHER MIXED
AL AL
Neuropathy VASCULA
PatHogenesis
PERIPHERAL NEUROPATHY PERIPHERAL VASCULAR
HIPERGLYCEMIA DISEASE
• ↓ myoinositol for neuronal • Endothelial & peripheral arterial
conduction myocite dysfunction
• NADP storage depletion unable • thromboxane A2
to detoxify ROS & sinthesize NO =
= • Vasoconstriction
• Vasoconstriction • Hipercoagulable plasma
• Oxidative stress Cell injury & =
death Neuronal dysfunction ISCHEMIC of lower limbs
Risk of diabetic foot ulcers
Neuropati motoric, autonomis &
sensoris
PATHOPHYSI
motoric Neuropathy OLOGY
Innervation damage of lowe limbs intrinsic muscle unbalanced flexion-
extention deformity abnormal bony prominence & pressure point
risk of skin damage& ulceration
Autonomic Neuropathy
Sweat & oil glands dysfunction dry skin risk of wound & infection
PATHOPHYSI
Sensoric NeuropatHY
exacerbates the
OLOGY
JOINT
DEFORMIT
Collagen glycolation thickening of periarticular
development of Y (tendon, ligament, joint capsule) joint
structure
ulcerations, patients deformity
are often unable to
detect the insult to
their lower
extremities, wounds
go unnoticed and
progressively worsen
DFU
CLASSIFICATION
BASED ON
ETIOLOGY
Wagner classification
PEDIS classification
STAGE OF THE DIABETIC
FOOT
DIAGNOSTIC
HISTORY APPROACH
• DM History : duration, medication adherence
• Disease History : Heart, kidney disease, visual disorder, allergy
• Lifestyle : Sports, Diet, Smoking, Alcohol Consumption
• Symptoms of Neuropathic & Ischemia: Anesthesia, Parasthesia, Pain,
Unable to sweat, atrophy
• Wound/Ulcer History: Location, duration, size, depth, temperature &
smell
• Footwear, history of chemical exposure, callus & deformity
SIGNS & SYMPTOMS
• Paresthesia
• ↓/(-) Pulsation of a.
• Resting pain
dorsalis pedis, tibialis &
• Claudication
popliteal
• Sensory loss
• Limb atrophy
• Necrosis
• Cold
• Dry Skin
• Abnormal Nail
Phisical DIAGNOSTIC
Examination APPROACH
• Inspection
• Skin : Color, turgor, cracked skin, anhidrosis, infection,
ulcer, callus, bullae, thinning hair
• Muscle: posture, deformity, claw toes, charcot joint, limited
joint motion, tendon, gait & strength.
PhYsical DIAGNOSTIC
Examination APPROACH
• Neurological Examination
• Monofilament Semmes Weinstein
+ one of:
• Tuning fork examination
• Heel Reflex
• Pinprick Test
• Biotensiometer (Vibration Test)
PhYsical DIAGNOSTIC
Examination APPROACH
• Blood Flow Test
• Arterial Pulsation of pedis
• Capillary refilling time
• Ankle brachial index
LABORATORY
FINDING
• Laboratorium : Blood Glucose (Random & Fasting), HbA1c,
CBC, Urinalysis
• X-Ray : Vascular imaging, diabetic osteopathy
• Culture Test
TREATMENT
METAB TIME
WOUND Tissue debridement
OLIC Blood glucose, Inflammation & Infection
albumin, Hb CONTR control
CONTR Moisture balance
OL Epithelial edge enhancement
OL
INFECTI Antibiotics VASCUL
ON indicated
infection with AR Surgery/angioplasty for
CONTR positive clinical
& culture of CONTR ischemic ulcers
OL infection
OL
PRESSURE
PreventCONTROL
& ↓ recurrent pressure, shearing forces, callus
management by healthcare professionals & wear size appropriate
footwear.
EDUCATION
CONTROL
Diabetic foot care
Amputation For Diabetic
ulcer?
Degree of Clinical Manifestation
Infection
COMPLIcAtIon 1 (No
Infection)
-
2 (mild) Superficial lesion, with minimal 2 of:
- warm on palpation
- Erythema > 0.5 – 2 cm
Infection - Local pain
- Induration
Amputation - Purulent
Deformity 3 (moderate)
Excluded other probable cause of infection
Erythema > 2cm with one of:
Osteoporosis - Infection of tissue below skin (subcutaneous)
No systemic response of inflammation
4 (Severe) Minimal 2 of systemic response:
- Temperature > 39 degree Celsius/ <36 degree C
- Respiration rate > 90x/minute
- PaCO2 < 32 mmHg
- Leucocyte > 12000 or <4000 U/L
- Immature lymphocyte >10%
PREVENTION &
EDUCAtION
- Foot hair thinning Early detection
- Anesthesia, Parasthesia,
- Nail abnormality of shape Unable to feel pain
& color
DIABETIC FOOT ULCER RISK
- Cold feet
- Callus - ChangeRisk
Categories of color (Redness, CATEGORIES
Factors Evaluation
- Deformity of toesi & Bluish, kehitaman) Recommendation
plantar aspect, bony 0 No sensoric neuropathy Every year
prominence 1 Sensoric neuropathy Every 6 months
2 Sensoric 2-3 months
neuropathy/peripheral
vascular disease/foot
deformity
3 History of 1-2 months
ulcer/amputation
- After 1, 3 and 5 years of observation
34%, 61% and 70% of the patients,
respectively, had developed a new
foot ulcer.
- The recurrence rate of foot lesions
PROGN
was slightly higher among patients
who previously had had an
amputation
OSIS - Amputation rates of patients with
previous primary healing vs
amputated in 1, 3 and 5 years were
3%, 10% and 12% vs 13%, 35%
and 48%.
SOURCE
1. PERKENI. Pengelolaan dan Pengobatan Diabetes Melitus Tipe 2 Dewasa. In:
Pedoman Pengelolaan dan Pencegahan Diabetes Melitus Tipe 2 di Indonesia. 2019. p.
72–6.
2. Clayton W. A review of the pathophysiology, classification, and treatment of foot
ulcers in diabetic patients. Clin Diabetes. 2009;27(2):52–8.
3. Pendsey SP. Understanding diabetic foot. Int J Diabetes Dev Ctries. 2010
4. Weledji EP. Treatment of the diabetic foot - to amputate or not? BMC Surg.
2014;14(1).
5. Bowyer G. Chapter 21: The ankle and foot. In: Blom AW, Warwick D, Whitehouse
MR, editors. Apley & Solomons System of Orthopaedics and Trauma Tenth Edition..
6. Morbach S, et al. Long-term prognosis of diabetic foot patients and their limbs:
Amputation and death over the course of a decade. Diabetes Care.
THAN
K YOU
CREDITS: This presentation template was created
by Slidesgo, including icons by Flaticon, and
infographics & images by Freepik
