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3 Steps for Diagnosing Diabetic Foot Osteomyelitis
Perform or order each of the following§ Probe-To-Bone test§ Erythrocyte sedimentation rate; consider C-reactive
protein and possibly Procalcitonin§ Plain X-rays
If DFO still suspected consider ordering one of the following:§ Magnetic Resonance
Imaging§ 18F-FDG- positron emission
tomography/computed tomography (CT)
§ Leukocyte scintigraphy (with or without CT).
Findings compatible with osteomyelitis?
YesNo
§ Strongly consider aseptically sampling affected bone (percutaneously or surgically, but not per wound) for culture and histopathology (if possible).
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Treat as soft tissue infection
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5 Steps to Manage Acute Charcot Neuro - Osteoarthropathy
1CLINICAL PRESENTATION
In patients with neuropathy§ Red§ Hot§ Swollen foot
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Suspect Charcot Foot
Yes
In case of ulcer§ Infection§ Underlying
osteomyelitis
Exclude common pathologies
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Pain not prominent
PLAIN X-RAY
Negative
Magnetic Resonance Imaging
(Cast while waiting)
Positive
NEGATIVE
Positive
BELOW KNEE CAST + CRUTCHES AND REFER TO A SPECIALISED DIABETIC FOOT UNIT
Imaging techniques
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§ Gout arthritis§ Deep vein
thrombosis (positive duplex vein scan)
§ Joint distortion§ Cellulitis
How to Manage People who are at Risk of Diabetic Foot Ulceration (DFU) ?
Very Low RISK High RISK
NO Loss of Protective Sensation(LOPS)
NO Peripheral Artery Disease(PAD)
LOPSORPAD
LOPS + PADOR
LOPS + Foot deformityOR
PAD + Foot deformity
LOPS OR PAD +
§ History of DFU§ Major or minor amputation
OR
§ End stage renal disease
Low RISK Moderate RISK
ExamineONCE A YEAR
ExamineONCE EVERY 6 MONTHS
ExamineONCE EVERY 3 MONTHS
ExamineONCE EVERY 1-3 MONTHS
Examine for signs and symptoms of LOPS and PAD
Screen for risk factors: DFU, amputation, renal disease, foot deformities, LJM*, pre-ulcerative signs, callus
Provide with foot care: education, removal of callus and nail care
Provide with appropriate therapeutic footwear + orthotic devices
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Provide with appropriate custom-made footwear (if foot deformitieor pre-ulcerative sign is present)
Instruct to self-monitor foot skin temperatures
Advise to perform foot and mobility-related exercises
*Limited Joint Mobility
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How to Perform Vascular Assessment in a Person with Diabetes and a Foot Ulcer?
Palpation of foot pulses § Pedal Doppler arterial waveforms§ Ankle systolic pressure and ankle brachial index§ Toe systolic pressure and toe brachial index
CONSULTATION WITH VASCULAR SPECIALIST
§ Triphasic Doppler waveforms§ Ankle brachial index 0.9-1.3§ Toe brachial index ≥ 0.75
Severe ischemia:§ Ankle systolic pressure <50mmHg or§ Ankle brachial index < 0.5 or§ Toe pressure <30mmHg
PAD is less likely
Presence of foot pulses does not
reliably exclude PAD
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Abnormal values but not severe ischemia:Is there infection or ulcer deeper than skin?
Irrespective of the results of
bedside tests, when the ulcer is not
healing within 4-6 weeks:
Yes
No
Posterior tibial arteryDorsalis pedis artery Ankle systolic pressure Toe systolic pressure
How to Classify Diabetic Foot Infection?
Infection severity
Antibiotics *
Clinical presentation
Characteristics
MILD INFECTION (IDSAa)-PEDISb 2 MODERATE INFECTION (IDSA)-PEDIS 3/3osteomyelitis
Presence of at least two of:
§ Local swelling or induration§ Erythema > 0.5 cm § Local tenderness or pain§ Local increased warmth§ Purulent discharge
Oral agents Oral or initial parenteral agents Parenteral agents
§ Local infection with erythema >2 cmOR
§ Involvement structures deeper thanskin and subcutaneous tissue
§ No signs of systemic inflammatoryresponse
SEVERE INFECTION (IDSA)/PEDIS 4/4osteomyelitis
§ Temperature >38 °C or <36 °C § Heart rate >90 beats/minute § Respiratory rate >20 breaths/minute
or PaCO2 <4.3 kPa (32 mmHg) § White blood cell count
>12,000/mm3, or <4,000/mm3, or >10% immature (band) forms
* See recommendations of Infection Guideline for empirical antibiotic regimenfor diabetic foot infection
a IDSA: Infectious Disease Society of Americab PEDIS: Perfusion, Extent, Depth, Infection and Sensation
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