279. Diabetic Foot Ulcers
Hello and welcome back to surgery one the podcast series. Brought to you with health of the department of surgery at the university of Albert this Jonathan white coming to you from the ROY exander hospital in lovely Edmonton. Alberta in this week's episode. We'll be hearing from medical student Rondo tools -i who comes to us from the university of Janna. His topic is going to be diabetic foot Alzheimer's. He'll be considering why people get them what they looked like on what we should do about them. So let's get ready to dig deep into the diabetic foot ulcer here on surgery one. Oh one. Hello. My name is Randolph and a medical student from the university of Ganda today. We'll be discussing diabetic foot ulcers in this episode. I will define diabetic foot alters explained relevant pathophysiology give you a clinical pitcher state. How it is diagnosed and finally we'll speak on its management. Looking after patient the diabetic foot alter can be a daunting task for medical student. I remember being very shocked to see a large gaping hole with numerous maggots in the foot of my very first surgical patient while in clerkship, but would exposure to and understanding off the disease management of diabetic foot ulcers can be streamlined. Would that said let's begin. With a case you're in the final week of your general surgery clerkship when the resident on your team acts you to see a patient in emergency room who has diabetic foot ulcer as you make your way to the ER you recall, the notes you made undeveloped authors. You remember reading the diabetic foot Alzheimer's are complex chronic wounds. That result from various changes in neuro vascular physiology, muscular-skeletal architecture, an immunologic response owing to chronic hyperglycemia. In diabetics these wounds are the number one cause of hospitalization in diabetics and can result in significant mortality and reduce quality of life. So why is diabetic foot ulcer important condition? Diabetic foot ulcers are common surgical pathology. With fifteen percent of diabetics developing foot ulcer and twelve to twenty four percent of individuals with. Title, sir, requiring amputation each year being able to recognize diabetic foot ulcer is important to primary care physicians as delayed treatment is associated with a significant risk for limbless with diabetic ulcers accounting for more than half of all non traumatic amputations. So why does it occur? The formation of diabetic ulcers are a result of a combination of pathological changes which occur over long periods of high blood sugar exposure, these changes can be grouped as one peripheral arterial scheme era and two preferable neuropathy, purple arterial ski Mia refers to neuro vascular actress, fluorosis and micro vascular endothelial dysfunction. This is ju- to increase calcification and metabolic abnormalities such as high LDL levels would increase pleaded adhesion reduce circulation compromises both tissue healing and infection. Control. A neuropathy refers to progressive loss of sensory motor and autonomous nervous functions. This results from increase intracellular, Surbiton accumulation, and micro vascular scheme you? So they are number of predisposing factors that result from perform neuropathy that would lead to limb injury. Let's discuss them. Now firstly there's a loss of protective sensation which increases the chances of unrecognised trauma and late wouldn't presentation, then autonomic dysfunction leads to dry cracked scaly skin, which makes bacterial seeding into deeper tissue, easy, and as such infections can propagate turdly. They can be motor dysfunction, which would lead to loss of the normal foot. Architecture would abnormal pressure points and subsequent alterations developing. When those factors are combined with an initial injury, a chronic soft tissue wound can develop what a superimposed bacterial infection that will lead to loss of limb function and may possibly lead to sepsis. So at this point, we're walking over to meet the patient at the bed and had you just read that missions chart. You read that patient. Mr. Jeeves is a sixty seven year old meal with a long standing history of diabetes mellitus type two who has had poor glycemic control for a number of years. He came to the yard complaining of pain and pus discharge from a wound on his left foot. You introduce yourself and begin to take a history from him you recall, the diagnosing diabetic foot also hinges on detail history taking and meticulous physical examination. In addition to taking the history of the presenting complaint, a physician should focus on symptoms of possible per floor, neuropathy or peripheral arterial schema such as hyper seizure, Paris, Dijon and cloudy -cation understanding of their diabetic history. Glycemic control medication use. Activity status are also crucial to management. Mr. Jeeves tells you that he is had no miss an a tingling sensation to both legs for years now and sometimes cannot feel small injuries to them. He says that he hasn't seen a doctor in six months and has run out of medication tree months ago after detail history yet, Mr. achieve if you can examine both legs wanting to compare the affected and unaffected limbs on examination you bear. In mind. Typical presentation of diabetic foot ulcers alters tend to occur over areas of weight bearing such as the heal. The plantar metatarsal heads an over the Malia lie. The wounds can vary in depth size. A number with some wounds forming complex tracks owing to secondary infection. Other telltale signs that may point a physician to diagnosis of diabetic foot. Ulcers are one dry cracked hairless skin. To the loss of the plantar arch. Tree calluses in four brittle nails. After thorough inspection of both limbs, you'll remember that detail physical examination for diabetic foot ulcers involve for competence one. Dumped a logic noting skin color cracks fissures, Dima, blisters and temperature to muscular skeletal looking for cloth. Does hammer toes prominent metatarsal heads bunions overlapping toes, muscle wasting and shark. Odds foot, which is a flat. Bottom foot Juta, joint, instability, and muscle atrophy tree neurologic inspecting for sensation loss with the monofilament tests testing for ankle reflexes and vibration perception and for vascular where we evaluate for flow foot pulses, and in some cases, taken ankle break you'll index. As you're finishing your exam. Your resident arrived, so you Mr. Jeeves in proceed to present your findings. The resident is impressed with your level of detail and commence your before you leave you act a resident how we will manage Mr. gave reminds you that we're treating the whole patient not just his foot and so- relates the goals of management for diabetic foot ulcers. They are as follows one provide local wound care to restore adequate blood supply tree pressure off loading and for treating underlying cause we will now discuss each of these in detail. So let's start with local wound-care this involves surgical debrief -ment, infection control, an optimal dressing, the most common method us is sharp surgical debasement where operative techniques are used to remove dead Macronix, Lafayette issues in drain pus. Effective, debris. It meant allows for complete is Asian and wound closure, but they are out of farms divide -ment such as hydrologic derived -ment and larval therapy, infection control can be achieved with broad spectrum antibiotics with subsequent antibiotic choice usually dependent on tissue cultures. The normal duration of antibiotics is usually one tree weeks. Next is restoring adequate circulation. Adequate circulation is crucial to infection control, an optimal. Healing early. Revitalization. Can reduce the risk of amputations indications for revalorisation include necrosis and signs of critical. Limit ski Mia such as reduced or absent pulse. Feeling a limb that is cold to touch and obvious power of limb surgical options for birth. Little artery disease include vascular bypass, or Angie. Oh, plastic with stent placement. Turdly is pressure off loading. This is a highly individualized process where specialized Cass and footwear are used to shift pressure away from at risk areas of the foot in order to redistribute pressures evenly across the foot, while weight bearing I still encourage healing and prevent farther. Also rations finally management of a patient with a diabetic foot ulcer is never complete without initiating are optimizing diabetic treatment to restore proper glycemic control an easy way to remember steps involved in managing diabetic patient after surgical interventions is to use the a b c d e s approach a is for a one c goal. So we would optimize the patient's medication to achieve an individualize. Hba? One Siegel be for blood pressure and short tight blood pressure. Control with appropriate. Medication and sodium restriction. Cease for cholesterol, prescribed statins to lower cholesterol levels. D is for diet emphasize low car blow fat diet that is rich in protein. ES for an exercise plan. Initiates an exercise plan that is individualized each patient taking into consideration their activity status and disability level S is for smoking advice smoking cessation. The next morning. Your resident tells you that Mr. achieve had local wound care was restarted an appropriate medications and did not require an MP tation, your tangled hair, this and hope that Mr. g follows output, his family doctor. Okay. We've set a lot in this episode. So let's recap diabetic foot alters our common complication of diabetes. It is a chronic wound farm from an initial injury compounded by poor circulation and healing. Patients present with a non healing ulcer to pressure points foot that may be infected or contain gangrenous to sue. A thorough near vascular examination is required before treatment surgical management. Involve sharp do bright -ment broad spectrum antibiotics and frequent dressing changes. And finally, don't forget to treat the cause. Thank you for listening. Thanks Rondo for that. Awesome. Overview off such a common topic, please checkered all of our other episodes at surgery one one dot org. Thanks for listening. I will see you back here next week on surgery one. Oh one.