The Diabetic Foot The Diabetic Foot Management Center Management Center

introducesintroduces

Dr. Susan HolibaughDr. Susan Holibaughpresentingpresenting

“Don’t let Diabetes Defeet “Don’t let Diabetes Defeet Us”Us”

Diabetes StatisticsDiabetes Statistics

According to the According to the American Diabetes American Diabetes Association, Association, there are 18.2 million people there are 18.2 million people in the United States in the United States 6.3% 6.3% of the population of the population who have diabetes.who have diabetes.

While an estimated 13 million have been While an estimated 13 million have been diagnosed there are 5.2 million or 1/3 who diagnosed there are 5.2 million or 1/3 who have not yet been diagnosed. have not yet been diagnosed.

DiabetesDiabetes is not readily detected during is not readily detected during the first the first seven years seven years of the disease in of the disease in many patients.many patients.

Diabetes Statistics for AmericansDiabetes Statistics for Americans

Diabetes is a chronic disease Diabetes is a chronic disease for which there is no cure, but for which there is no cure, but there is there is controlcontrol

Diabetes is the 5Diabetes is the 5thth deadliest deadliest disease in the United States disease in the United States and accounts for approximately and accounts for approximately 213,000 deaths per year 213,000 deaths per year

How many types of Diabetes are How many types of Diabetes are there?there?

There are two type of diabetes: Type There are two type of diabetes: Type I and Type II I and Type II

Type 1 Diabetes is when the Type 1 Diabetes is when the pancreas makes virtually no insulin.pancreas makes virtually no insulin.

Type 2 diabetes occurs when the Type 2 diabetes occurs when the pancreas cannot make enough pancreas cannot make enough insulin to fulfill the body’s insulin to fulfill the body’s requirements to keep the blood requirements to keep the blood glucose at normal levels.glucose at normal levels.

Diabetes Statistics 2005Diabetes Statistics 2005

There are 18.2 million people in There are 18.2 million people in the United States or 6.3% of the the United States or 6.3% of the population who have diabetes. population who have diabetes. While an estimated 13 million While an estimated 13 million

have been diagnosed an have been diagnosed an estimated 1/3 have not yet been estimated 1/3 have not yet been diagnosed and are unaware that diagnosed and are unaware that

they have the disease they have the disease

For Men –8.7% over the age of 20For Men –8.7% over the age of 20 Women – 8.7% of all over the age of 20Women – 8.7% of all over the age of 20 For Seniors – 18.3% of all patients over For Seniors – 18.3% of all patients over

the age of 60 (8.6 million), accounts for the age of 60 (8.6 million), accounts for over half of the diagnosed patients with over half of the diagnosed patients with diabetesdiabetes

Native Americans – 27% of all over the Native Americans – 27% of all over the age of 20, an epidemic proporationage of 20, an epidemic proporation

Approximately 2.7 million or 11.4% of all Approximately 2.7 million or 11.4% of all African Americans aged 20 years or African Americans aged 20 years or older have diabetes. However, one-older have diabetes. However, one-third of them third of them do notdo not know it. know it.

What are the complications of What are the complications of Diabetes?Diabetes?

CardiovascularCardiovascular disease caused by disease caused by atherosclerosis (excess buildup on the inner atherosclerosis (excess buildup on the inner wall of a large blood vessel) accounts for wall of a large blood vessel) accounts for approximately 25% of deaths among patients approximately 25% of deaths among patients with onset of diabetes before 20 years of agewith onset of diabetes before 20 years of age

BlindnessBlindness due to diabetic retinopathy due to diabetic retinopathy Kidney diseaseKidney disease affects 10 - 21% of patients affects 10 - 21% of patients

with diabeteswith diabetes NeuropathyNeuropathy due to decreased or damaged due to decreased or damaged

nerve function resulting in a loss of protective nerve function resulting in a loss of protective sense affecting 10-15% of patients with sense affecting 10-15% of patients with diabetesdiabetes

in your feetin your feet

There are two basic types of There are two basic types of diabetic neuropathy diabetic neuropathy

Peripheral neuropathy is damage of the Peripheral neuropathy is damage of the nerves closest to the skin and occurs most nerves closest to the skin and occurs most commonly in the feet and in the hands and commonly in the feet and in the hands and is symmetrical on both sides of the bodyis symmetrical on both sides of the body

Autonomic neuropathy is damage to the Autonomic neuropathy is damage to the nerves connected with our vital organs nerves connected with our vital organs and result in the inability to interpret and result in the inability to interpret internal pain correctly such as the “silent internal pain correctly such as the “silent heart attack”heart attack”

““Silent” heart attackSilent” heart attack

The most life threatening consequences The most life threatening consequences of diabetes are of diabetes are heart disease and strokeheart disease and stroke, , which strike people with diabetes more which strike people with diabetes more than twice as often as they do others. than twice as often as they do others.

Because of neuropathy these attacks are Because of neuropathy these attacks are often “silent” and occur with little or no often “silent” and occur with little or no warning. warning.

Adults with diabetes have death rates 2 to Adults with diabetes have death rates 2 to 4 times higher than those without 4 times higher than those without diabetes. diabetes.

AmputationsAmputations

From 2000-2001, there were From 2000-2001, there were approximately 82,000 below approximately 82,000 below knee amputations which are knee amputations which are related to diabetes compared to related to diabetes compared to 55,000 from 1995-199655,000 from 1995-1996

Today we are over 90,000+Today we are over 90,000+ All of the conditions you are All of the conditions you are

about to see, as simple as they about to see, as simple as they may seem can lead to lower may seem can lead to lower extremity ampuationextremity ampuation

Onychomycosis (fun“gal” or Onychomycosis (fun“gal” or fun“guy”) toenailfun“guy”) toenail

Another “funguy”Another “funguy”

Why do I get Fungus?Why do I get Fungus?

““Fungus” or onychomycosis is caused by Fungus” or onychomycosis is caused by trauma to the nail bed, predisposition to trauma to the nail bed, predisposition to dermatological disorders, and the natural dermatological disorders, and the natural processes of aging. While this has been processes of aging. While this has been termed an infection, it is not contageous, termed an infection, it is not contageous, rarely causes harm, but is considered rarely causes harm, but is considered unsightly. Today, the best treatments unsightly. Today, the best treatments include topical medications and regular include topical medications and regular debridements. Oral medication has not yet debridements. Oral medication has not yet proven to be successful despite the media proven to be successful despite the media marketingmarketing

Fungal Nails with Severe Ischemia Fungal Nails with Severe Ischemia (poor circulation)(poor circulation)

The athelete of the footThe athelete of the foot

Severe athelete’s foot (tinea pedis)Severe athelete’s foot (tinea pedis)

Hammertoes and cornsHammertoes and corns

Repeat offenders, corn plastersRepeat offenders, corn plastersone toe already goneone toe already gone

Lamb’s wool or a wise choiceLamb’s wool or a wise choice

Dry and painfulDry and painful

Skin cracks can lead to infectionSkin cracks can lead to infection

Xerosis – extremely dry skin Xerosis – extremely dry skin with heel cracking and “fish with heel cracking and “fish

like scales”like scales”

Two weeks after appropriate skin Two weeks after appropriate skin care “the recipe”care “the recipe”

High uric acid is from what? High uric acid is from what?

Uric Acid is something the body produces and if it cannot secrete it or Uric Acid is something the body produces and if it cannot secrete it or

if too much is produced then the crystals precipitate (form) in the joints if too much is produced then the crystals precipitate (form) in the joints causing gouty tophi. Many items in our diets lead to gout. Alcohol, red causing gouty tophi. Many items in our diets lead to gout. Alcohol, red meats, dark green vegetables. Some of our medications produce gout meats, dark green vegetables. Some of our medications produce gout attacks too such as blood pressure medications; all of which should be attacks too such as blood pressure medications; all of which should be

addressed when gout is diagnosed.addressed when gout is diagnosed.

Gout can be leathal to a diabetic – Gout can be leathal to a diabetic – How bad can this get?How bad can this get?

Gout of both feet, gouty tophic, long Gout of both feet, gouty tophic, long term problem with cottage cheese term problem with cottage cheese

like dischargelike discharge

Melanoma is the most unexpected Melanoma is the most unexpected placesplaces

Inflammation and dermatitisInflammation and dermatitis

Atherosclerosis (arterial Atherosclerosis (arterial calcification) of the footcalcification) of the foot

The renal transplant patient is 250 The renal transplant patient is 250 times more likely to get skin times more likely to get skin

cancers: basil cell carcinomacancers: basil cell carcinoma

Squamous cell carcinoma: If too Squamous cell carcinoma: If too extensive, a tragic loss can resultextensive, a tragic loss can result

Squamous Cell Carcinoma; same Squamous Cell Carcinoma; same patient with recurrencepatient with recurrence

What is Neuropathy?What is Neuropathy? One of the most common complications of One of the most common complications of

diabetes and it means simply this: as diabetes and it means simply this: as blood sugar become elevated, nerves blood sugar become elevated, nerves closest to the skin become either closest to the skin become either temporarily or permanently damaged temporarily or permanently damaged depending on the extent and control of depending on the extent and control of the disease. the disease.

The result is lack of sensation in the toes, The result is lack of sensation in the toes, foot, ankle and sometimes the legfoot, ankle and sometimes the leg

This creates a loss of protection that a This creates a loss of protection that a normal patient maintains: the “anesthetic” normal patient maintains: the “anesthetic” foot which results in ulcers and infection foot which results in ulcers and infection 10-15% of the time.10-15% of the time.

What causes neuropathy?What causes neuropathy?

The leading cause of neuropathy is The leading cause of neuropathy is DiabetesDiabetes

Other causes include, but are not Other causes include, but are not limited to, alcoholism, spinal cord limited to, alcoholism, spinal cord lesions, back injuries, liver lesions, back injuries, liver dysfunction, anemia, dysfunction, anemia, hypervitaminosis, muscular hypervitaminosis, muscular dystrophy, multiple sclerosis, dystrophy, multiple sclerosis, hypothyroidism, lupus, lyme disease, hypothyroidism, lupus, lyme disease, tertiary syphyllis, and leprosytertiary syphyllis, and leprosy

Dropfoot with 2Dropfoot with 2ndnd toe ulcer toe ulcer

Ulcers: the greatest complication of Ulcers: the greatest complication of neuropathyneuropathy

New shoes one dayNew shoes one day

Another repeat offenderAnother repeat offender

““I couldn’t feel it; I couldn’t see it, I couldn’t feel it; I couldn’t see it, but I could smell it doctor”but I could smell it doctor”

Midfoot ulcerationMidfoot ulceration

Ulcers should be measured for Ulcers should be measured for length, width and depth at each length, width and depth at each

visit for treatment visit for treatment

Whirlpooled for one yearWhirlpooled for one year

Ulcers commonly occur in high Ulcers commonly occur in high areas of pressure or dry skinareas of pressure or dry skin

Stasis ulcerations are due to vein Stasis ulcerations are due to vein dysfunction in the legdysfunction in the leg

Stasis ulcer of the ankleStasis ulcer of the ankle

Wound care and antibiotics can Wound care and antibiotics can make all the differencemake all the difference

Post polio and diabetesPost polio and diabetes

Charcot ArthropathyCharcot ArthropathyA special kind of problemA special kind of problem

Charcot occurs one in every 500- Charcot occurs one in every 500- 750 diabetic patients. Note 750 diabetic patients. Note

complete ankle collapsecomplete ankle collapse

The first sign of Charcot, is swelling and The first sign of Charcot, is swelling and redness with subsequent loss of the redness with subsequent loss of the

ligamentsligaments

Charcot with complete collapse of Charcot with complete collapse of the ankle and midfootthe ankle and midfoot

Xray of Charcot foot with midfoot Xray of Charcot foot with midfoot collapse collapse

Ulcers caused from Charcot may Ulcers caused from Charcot may be sterile initially but can result in be sterile initially but can result in

tissue and bone infection if left tissue and bone infection if left untreated.untreated.

. Charcot arthropathy after surgical . Charcot arthropathy after surgical intervention. intervention.

Fluid OverloadFluid Overload

Neuropathy and Infection:Neuropathy and Infection:Hot water from the stoveHot water from the stove

AnAn ingrown toenail of a normal patient ingrown toenail of a normal patient

A diabetic patient with an infected A diabetic patient with an infected ingrown toenail…..another ingrown toenail…..another

bathroom surgeon Note the tight bathroom surgeon Note the tight skin and lack of hairskin and lack of hair

And if our infection is left untreated? Our And if our infection is left untreated? Our greatest fear becomes a tragic loss.greatest fear becomes a tragic loss.

Gangrene after an infected ingrown toenailGangrene after an infected ingrown toenail

Brown recluse spider biteBrown recluse spider bite

Gangrene after spider bite in a patient with Gangrene after spider bite in a patient with little or no circulation: dialysislittle or no circulation: dialysis

OsteomyelitisOsteomyelitis

Dry gangrene; from infectionDry gangrene; from infection

Gangrene of the 2Gangrene of the 2ndnd toe toe“But doctor I didn’t feel anything”“But doctor I didn’t feel anything”

Same patient opposite footSame patient opposite foot

Gangrene and burns: A hot plate of Gangrene and burns: A hot plate of spaghetti spaghetti

Ten years ago this probably would Ten years ago this probably would have been amputatedhave been amputated

A blood clot in January: Complete A blood clot in January: Complete breakdown of the lower extremity by March breakdown of the lower extremity by March with Gangrene with yet another tragic loss: with Gangrene with yet another tragic loss:

above knee amputation above knee amputation

Cold exposure and dry gangreneCold exposure and dry gangrene

The patient arrives at the hospital for a The patient arrives at the hospital for a serum blood glucose and asks, “can serum blood glucose and asks, “can

somebody check my foot?somebody check my foot?” ”

Gas or Wet gangreneGas or Wet gangrene

But still the foot can be savedBut still the foot can be saved

How to save a leg with poor blood How to save a leg with poor blood supply? Femoral (above the knee) supply? Femoral (above the knee)

to popliteal (behind the knee) to popliteal (behind the knee)

to dorsalis pedis (on top of the foot) to dorsalis pedis (on top of the foot) bypass graftbypass graft

Repetitive mechanical pressure x 2 Repetitive mechanical pressure x 2 yearsyears

Three weeks after surgeryThree weeks after surgery

Foot care Don’tsFoot care Don’ts

DON’T soak or scrub feetDON’T soak or scrub feet Don’t use drying medicines like iodine Don’t use drying medicines like iodine

or medicated corn padsor medicated corn pads Don’t try to trim corns, callouses or Don’t try to trim corns, callouses or

ingrowing toenailsingrowing toenails Don’tDon’t go barefoot ever!!!!go barefoot ever!!!! Don’t wear tight shoes, socks or gartersDon’t wear tight shoes, socks or garters Don’t ignore any foot or leg problem; Don’t ignore any foot or leg problem;

even small ones can get serious!!even small ones can get serious!!

The Five “C’s” of Foot Care The Five “C’s” of Foot Care Clean! Clean and check feet daily. Wash Clean! Clean and check feet daily. Wash

with warm with warm not hotnot hot water. Pat dry. water. Pat dry. Condition!! Use a moisturizer daily. Use Condition!! Use a moisturizer daily. Use

one without perfume or alcoholone without perfume or alcohol Care!!! Clip normal nails straight across with Care!!! Clip normal nails straight across with

a slight curve at the corners. a slight curve at the corners. Bathroom Bathroom surgeons give up your license.surgeons give up your license.

Cover!!!! Always wear shoes or slippers with Cover!!!! Always wear shoes or slippers with a sole to protect your feet. Check your feet a sole to protect your feet. Check your feet before and after wearing for any unusual before and after wearing for any unusual marks or rednessmarks or redness

Use caution and callUse caution and call

““It’s okay, you can wake up now.”It’s okay, you can wake up now.”