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Curriculum(VitaeA.(Personal(Iden5ty
B.(Educa5on&(Training((
C.(Organiza5on(
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Early Detection and
Prevention of Diabetic Foot
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Learning Objectives
• Identify risk factors and strategies for early
detection of diabetic foot
• Explain the pathophysiology and etiology ofdiabetic foot
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People with Diabetes
Increased risk of hospitalized and infection
Have a 15 % life time risk of developing foot ulcer
Have 15 – 40 fold higher risk of leg amputation
Every 30 seconds a lower limb lost caused by diabetes
85 % of amputations are preceded by foot ulcer
Early detection can prevent 40-85 % lower limb amputation
Frykberg RG, et al. J Foot Ankle Surg, 2000
IDF , International Working Group on Diabetic Foot 2007
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Outcome
(19) 44%
(11) 25%
(5) 12%
(3) 7%(5) 12%
n = 43 patients
Improved
Minor Amputation
Major Amputation
Died
Self request
discharge
no amputation amputation death
50 %15 %
35 %
Source:
Speaker Meeting
Kyoto Foot Meeting 2008Em Yunir, Kyoto Foot Meeting 2012
No amputation Amputation Death
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Pathophysiology of Diabetic Foot
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Risk Factors of Diabetic Foot
Peripheral neuropathy
Peripheral vascular disease ( PAD )
Foot Deformities/ biomecanic
History of ulcer or amputationNon suitable footwear
Lack of access to health care
services
Edmond M, 2006
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Risk Factors
10/11/2015 Kyoto Foot Meeting 2010 9
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Peripheral Neuropathy
1. Autonomic Neuropathy
2. Motor Neuropathy
3. Sensoric Neuropathy
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Autonomic neuropathy
Decreased sweating
Dry skin
Decreased elasticity
Repetitive Shears &
Pressures
Callus/ Fissure
Ulcer
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Thermal trauma by hot water
Ill fitting shoes
Thermal trauma in `bajaj`
• Loss protective sensation• Decreased of pain threshold
• Lack of temperature sensation and proprioseption
Sensoric neuropathy
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kaki :
Small musclewasting/hypotrophy
foot deformities
bone prominent
Increased foot pressure
Ulcer
Somatic Motor Neuropathy
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• Correlated with atherosclerosis
• A1c 1 % 26 % PAD
• More aggressive
• Narrowing vessel lumen … obstructive
• Distal tissue necrosis
Peripheral Arterial Disease
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Normal FattyStreak
FibrousPlaque
Athero-scleroticPlaque
PlaqueRupture/Fissure &
Thrombosis
Clinically Silent
Increasing Age
Angina, TIA`s, PAD
IschemicStroke
MyocardialInfarction
Critical
LegIschemia
Cardiovascular Death
Macrocirculation
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Assesment Test Significants Findings
Patients History Interview Previous foot ulceration
Previous amputation
Diabetic > 10 years
A1c > 7 %Impaired vision
Neuropatic symptoms
Claudicatio
Diabetic Foot Examination
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Assesment Significant finding
Gross inspection Hammartoes
Claw toes
Halux valgus
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Deformity
Prominent MTP I
Hammer toes
Claw toes Pes Cavus
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Assesment Significant finding
Gross inspection Deformities, Corn, calluses, bunionCallus with ulcer
Prominent metatarsal head
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Callus (1)
Callus + ulkusCallus
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Assesment Significant finding
Dermatologic examination Dry skinAbsence of hair
Yellow or erythematous scale
Ulcer
Heal Ulcer
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Assesment Significant finding
Dermatologic examination Interspace maserationMoist
Uhealing ulceration
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Assesment Significant finding
Nail deformities Yellow, thickened nailIngrowing nail edge
Long or sharp nail
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Assesment Test Significant finding
Screening forneuropathy
Semmes-Weinsteinmonofilamen 10 gram
Lack of perseption atone or more side
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Assesment Test Significant finding
Screening forneuropathy
Tuning fork 128 Hz Negative of vibrationperception
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Assesment Test Significant finding
VascularExamination
•Palpation of dorsalis
pedis and tibialis
posterior arteri
•Ankle Brachial Index
( ABI )
•Color doppler
•Decrease or absent
pulse
• ABI < 0.9 consistent
with PAD
M f h A kl B hi l I d (ABI)
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Measurement of the Ankle – Brachial Index (ABI).
Source: American Heart Association
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Interpreting the Ankle-Brachial pressure Index ( ABI )
ABI Interpreting
>1.2 Rigid or calcified vessels or both
0.9 – 1.1/1.2 Normal (or calcified)
<0.9 Ischaemia
<0.6 Severe ischaemia
Source: American Diabetes Association Cek nilai
ABI tertinggi versi ADA 2015
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Grade 1 Grade 2 Grade 3 Grade 4 Grade 5 Grade 6
Normal High risk
Deformity
Nail abnormality
Dry skinHypotrophy
muscle
Ulcus
Ulcus at plantar
Neuropathy
CallusMuscle at the
bottom
Infection foot
Edema
Rash
InfectionOsteomyelitis
Systemic
symptoms
Necrosis/
gangren foot --,
cutis, subcutis
fascia, joint.
Irreversible
Extensive
necrosis, should
be treated with
amputation
Wagner Classification
linical Manifestation
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5 Cornerstones of Foot Management
Footexamination
Classificationrisk factors
EducationAppropriate
footwear
Treatment before ulcer
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Do:
1. Check and take a look your feet everyday
2. Always using footwear
3. Check your shoes before wearing
4. Wearing proper shoes5. Buy shoes in afternoon
6. Always wearing cotton socks
7. Wash your feet with smooth soap, dry it
8. Clipping nail horizontally
9. Check your feet to health care professional
regularly
10. Use moisturizing lotion regularly
Prevention Program
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Summary
• Diabetic foot is one of chronic complications ofdiabetes
• Pathophysiology of diabetic foot ias very complex
• Slow healing process, risk for ulcus to be chronicand high incidence of amputation
• Holistic management is mandatory and involvingmultidisciplines
•
Majority of ulcus or injury in diabetic foot can beprevented with early detection and prevention athigh risk of foot
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Skin (1)
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Bulu kaki yang menipis Atrofi jaringan subkutan
Skin (2)
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UlkusWarna kulit kaki kemerahan Tinea ( jamur )
Bullahiperpigentasi
Skin (3)
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Skin (4)
Maserasi kulit padasela jari
Bullae (tangan)
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Nail (1)
1. Structure :
- atrophy
- hypertrophy- fragile
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Kuku(2)
2. Change of color
3. Abnormality of nail growth
4. Infection
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Nail Abnormalities
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Swelling
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Halux valgus
Hammer toes
Claw toes Pes Cavus
Deformities
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Case Studies
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Clinical Features and Diagnosis?
Mention physical abnormalities on below
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Mention physical abnormalities on below
picture