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The foot is an extremely complex and flexible structure. It is composed of a network

of bones, joints, ligaments, and numerous muscles that work together to provide the
body with support, forward propulsion, adaptation to uneven surfaces, and
absorption of shock. The complex interaction of foot bones and joints allows the vast
range of motion exhibited by the foot during walking. Abnormal mechanical loading
of the foot, resulting in repetitive pressure applied to the plantar aspect of the foot
during walking, has an important role in the development of Diabetic Foot Disease.

The systematic examination of weight transmission and the walking mechanisms

offers perhaps one of the key elements in understanding the development of foot
ulcerations in patients with diabetes. In the standing position, the body weight is
transmitted from the femur and tibia through the heel bones (talus and calcaneus)
and the heads of the metatarsals to t he ground. During walking, the calcaneus has
an important role in the first two segments (heel strike and midstance) in providing
optimal gait for energy absorption and weight bearing. In the third segment of
walking, the muscles, tendons, and ligaments ti ghten to lift the calcaneus off the
ground (heel rise), and then the foot regains its arch in preparation for the last
segment (toe push-off).

The shearing forces during dynamic walking, in addition to the balance between the
forces of the pushing down of the body weight and the pushing up of the ground
reactive forces, create friction and compressive forces on the foot.Abnormalities in
foot biomechanics may result in a dysfunctional gait and can lead to structural
changes in the foot that increase the ri sk of ulceration and subsequent amputation.
Loss of sensation, especially at pressure points, may lead to persistent stress, which
may result in development of a bunion and subsequent skin breakdown and ulcer
formation. The deep aspect of the plantar apone urosis sends septa that divide the
plantar aspect of the foot into three major compartments: medial, central, and lateral
(Figure 2).
[(Figure 2). Schematic anatomic diagram of forefoot compartments. Deep soft tissue
infection is likely to spread along these compartments. Ô = central compartment; =
dorsal compartment;
= lateral compartment;  = medial compartment.]

These compartments contain the long flexor tendons and the tendons of intrinsic
muscles of the foot covered by synovial sheaths. Extensi on of infection into these
compartments might increase the intra compartmental pressure, which may further
interfere with the blood supply to the distal portions of the foot and thus exacerbate
the problem of ulceration and poor healing.

Every cell in the human body needs energy in order to function. The body¶s primary
energy source is glucose, a simple sugar resulting from the digestion of foods
containing carbohydrates (sugars and starches). Glucose from the digested food
circulates in the blood as a read y energy source for any cells that need it. Insulin is a
hormone or chemical produced by cells in the pancreas, an organ located behind the
stomach. Insulin bonds to a receptor site on the outside of cell and acts like a key to
open a doorway into the cell through which glucose can enter. Some of the glucose
can be converted to concentrated energy sources like glycogen or fatty acids and
saved for later use. When there is not enough insulin produced or when the doorway
no longer recognizes the insulin key, glucose stays in the blood rather entering the
cells.




  
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Diabetic foot is an umbrella term for foot problems in patients with diabetes mellitus.
It is better known as diabetic foot ulcer. Diabetic foot ulcer is one of the major
complications of Diabetes mellitus. It occurs in 15% of all patients with diabetes and
precedes 84% of all lower leg amputations.[1] Major increase in mortality among
diabetic patients, observed over the past 20 years is considered to be due to the
development of macro and micro vascular complications, including failure of the
wound healing process. Wound healing is a µmake-up¶ phenomenon for the portion of
tissue that gets destroyed in any open o r closed injury to the skin. Being a natural
phenomenon, wound healing is usually taken care of by the body¶s innate
mechanism of action that works reliably most of the time. Key feature of wound
healing is stepwise repair of lost extracellular matrix (ECM) that forms largest
component of dermal skin layer. Therefore controlled and accurate rebuilding
becomes essential to avoid under or over healing that may lead to various
abnormalities. But in some cases, certain disorders or physiological insult disturbs
wound healing process that otherwise goes very smoothly in an orderly manner.
Diabetes mellitus is one such metabolic disorder that impedes normal steps of
wound healing process. Many histopathological studies show prolonged
inflammatory phase in diabetic wounds, which causes delay in the formation of
mature granulation tissue and a parallel reduction in wound tensile strength





  
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³Infection, ulceration and/or destruction of deep tissues associated with neurological

abnormalities and various degrees of peripheral vascular disease in the lower limb of
a diabetic client is known as diabetic foot.´ (WHO, 1985)



 
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In a study to determine prevalence of diabetic foot in India, the prevalence of

infection noted was 6-11% and prevalence of amputation was 3% in type 2 diabetic
patients. In another Indian study, the prevalence of diabetic foot ulcers in the clinic
population was 3.6% as noted by Viswanathan Sociocultural practices such as
barefoot walking, religious practices like walking on fire, use of improper footwear
and lack of knowledge regarding foot -care attributes towards increase in the
prevalence of foot complications in India.17 Not only the prevalence of diabetic foot
ulcers, but Indian studies have also reported high recurrence of foot infection to be
more common among Indian diabetic patients (52%).

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IN BOOK IN CLIENT
Several risk factors increase a person with diabetes chances of developing
foot problems and diabetic infections in the legs and feet.

ë ?oorly fitting shoes are a common cause of diabetic foot

problems. If the patient has red spots, sore spots, blisters, corns, ?resent ( she
calluses, or consistent pain associated with wea ring shoes, new always wears
properly fitting footwear must be obtained as soon as possible. It also chappals)
develops if the patient has common foot abnormalities such as flat feet,
bunions, or hammertoes, prescription shoes or shoe inserts may be
necessary.

ë  ?eople with long-standing or poorly controlled

diabetes are at risk for having damage to the nerves in their feet. ?resent ( She
Because of the nerve damage, the patient may be unable to feel their has diabetes
feet normally. Also, they may be unable to sense the position of their for 15 yrs)
feet and toes while walking and balancing. Also a person with diabetes
may not properly sense minor injuries (such as cuts, scrapes, blisters),
signs of abnormal wear and tear (that turn into calluses and corns),
and foot strain. A person who has diabetes may not be able to perceive
a stone. Its constant rubbing can easily create a sore.
?resent
ë  !" # Especially when poorly controlled, diabetes can lead
to accelerated hardening of the arteries or atherosclerosis. When blood
flow to injured tissues is poor, healing does not occur properly.
?resent
ë
!$% Any trauma to the foot can increase the risk for a
more serious problem to develop.

ë
#% #&

@ Athlete's foot, a fungal infection of the skin or toenails, can lead to

more serious bacterial infections and should be treated promptly. Not present

@ Ingrown toenails should be handled right away by a foot specialist.

Toenail fungus should also be treated.

ë ' # Smoking any form of tobacco causes damage to the small
blood vessels in the feet and legs. This damage can disrupt the healing Not present
process and is a major risk factor for infections and amputations. The
importance of smoking cessation cannot be overemphasized.


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Diabetics are prone to foot ulcerations due to both neurologic and vascular
complications.
?eripheral neuropathy can cause altered or complete loss of sensation in the foot
and /or leg. Similar to the feeling of a "fat lip" after a dentist's anesthetic injection,
the diabetic with advanced neuropathy looses all sharp -dull discrimination. Any
cuts or trauma to the foot can go completely unnoticed for days or weeks in a
patient with neuropathy. It's not uncommon to have a patient with neuropathy tell
you that the ulcer "just appeared" when, in fact, the ulcer has been present for
quite some time. There is no known cure for neuropathy, but strict glucose control
has been shown to slow the progression of the neuropathy.
Charcot foot deformity occurs as a result of decreased sensation. ?eople with
"normal" feeling in their feet automatically determine when too much pressure is
being placed on an area of the foot. Once identified, our bodies instinctively shift
position to relieve this stress. A patient with advanced neuropathy looses this
important mechanism. As a result, tissue ischemia and necrosis m ay occur
leading to plantar ulcerations. Microfractures in the bones of the foot go unnoticed
and untreated, resulting in disfigurement, chronic swelling and additional bony
prominences.
Microvascular disease is a significant problem for diabetics and can lead to
ulcerations. It is well known that diabetes is called a small vessel disease. Most
of the problems caused by narrowing of the small arteries cannot be resolved
surgically. It is critical that diabetics maintain close control on their glucose level ,
maintain a good body weight and avoid smoking in an attempt to reduce the
onset of small vessel disease.

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Most experts use some variant of the classification system developed by Wagner
and most currently modified by Brodsky.

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0 At-risk foot, no ulceration ?atient education,
accommodative footwear,
regular clinical examination
1 Superficial ulceration, not Offloading with total contact cast
infected (TCC), walking brace, or special
footwear
3 Deep ulceration exposing Surgical debridement, wound
tendons or joints care, offloading, culture -specific
antibiotics
4 Extensive ulceration or Debridement or partial
abscess amputation, offloading, culture -
specific antibiotics

&$ "&& %  # 
A Not ischemic
B Ischemia without Non invasive vascular testing,
gangrene vascular consultation if
symptomatic
C ?artial (forefoot) gangrene Vascular consultation
D Complete foot gangrene Major extremity amputation,
vascular consultation

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Grade 1: Superficial Diabetic Ulcer

Grade 2: Ulcer extension

1. Involves ligament, tendon, joint capsule or fascia

2. No abscess or Osteomyelitis

Grade 3: Deep ulcer with abscess or Osteomyelitis

Grade 4: Gangrene to portion of forefoot

Grade 5: Extensive gangrene of foot

#" # : Client is in the depth classification of 3 , grade 2 and the ischemia
classification of µA¶ according to the classification of Wagger.



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IN BOOK IN CLIENT
 Early sign include:

- Redness of the skin Not ?resent

- Blistering
-Signs of irritation.

In the later stages:

- The person may encounter an open wound that drains fluid

onto socks or bedding All the late stages
- Infection on open wound symptoms
- Infected open wound develop swelling, redness, and present in the
drainage of pus patient
- Fever and blood sugar levels may be higher than usual


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IN BOOK IN CLIENT
Medical evaluation should include a thorough history and physical
examination and may also include laboratory tests, x-ray studies of
circulation in the legs, and consultatio n with specialists.

 &)#*$)& "+ # # First, the questions about their

symptoms and injured area will examine them. This examination Done
should include the patient's vital signs (temperature, pulse, blood
pressure, and respiratory rate), examination of the sensation in the
feet and legs, an examination of the circulation in the feet and legs, a
thorough examination of any problem areas. For a lower extremity
wound or ulcer, this may involve probing the wound with a blunt probe
to determine its depth.

,)&&

-*","""!#-: which will assist in determining Done

the presence and severity of infection. A very high or very low white
blood cell count suggests serious infection.

- "&!& # either by fingerstick or by a laboratory test.

Done
-Depending on the severity of the problem, the doctor may also order
kidney function tests, blood chemistry studies (electrolytes), liver
enzyme tests, and heart enzyme tests to assess whether other body
systems are working properly in the face of serious infection.

./.)&The x-rays studies of the feet or legs to assess for signs of

damage to the bones or arthritis, damage from infection, foreign Done
bodies in the soft tissues. Gas in the soft tissues, indi cates gangrene -
a very serious, potentially life -threatening or limb -threatening
 infection.

."&!# The doctor may order Doppler ultrasound to see the blood
flow through the arteries and veins in the lower extremities. The test is Done
not painful and involves the technician moving a non -invasive probe
over the blood vessels of the lower extremities.

.#&!" # The doctor may ask a vascular surgeon, orthopedic

surgeon, or both to examine the patient. These specialists are skilled
in dealing with diabetic lower extremity infections, bone problems, or Done
circulatory problems.

.c#  If the vascular surgeon determines that the patient has Not Done
poor circulation in the lower extremities, an angiogram may be
performed in preparation for surgery to improve circulation.

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The management of diabetic foot ulcers requires offloading the wound by using
appropriate therapeutic footwear, daily saline or similar dressings to provide a moist
wound environment, debridement when necessary, antibiotic therapy if osteomyelitis
or cellulitis is present, optimal control of blood glucose, and evaluation and correction
of peripheral arterial insufficiency. 

There are two main steps in the medical management of the diabet ic foot¶:

 Care of the wound

 Debridement of the wound
 Control of blood sugar and antibiotic therapy

CARE OF WOUND:

þ Wound coverage by cultured human cells or heterogeneic dressings/grafts,

application of recombinant growth factors, and hyperbaric oxygen treatments
also may be beneficial at times.
þ Intractable, infected, cavity wounds sometimes improve with hydrotherapy
using saline pulse lavage under pressure (?ulsEvac).
þ Clean but non healing deep cavity wounds may respond to repeated
treatments by application of negative pressure under an occlusive wound
dressing (vacuum-assisted closure [VAC]).
þ Hyperbaric oxygen therapy is used rarely and is certainly not a substitute for
revascularization.
þ Charcot foot is treated initially with immobilization using s pecial shoes or
braces but eventually may require podiatric surgery such as ostectomy and
arthrodesis. If neglected, ulceration may occur at pressure points, particularly
the medial aspect of the navicular bone and the inferior aspect of the cuboid
 bone. The various dressing materials used in wound dressing of a diabetic
patient.
) 
#  #&

#&*#% "& ² polyurethane film with Dry tominimally draining
adhesive layer; semipermeable
 ² polyurethane foam; open cell, Moderate, large exudates clean
absorbent  wound surface
)"& ² gel, sheet, gauze; 95% water Dry tominimally draining
or glycerin 
)"" & ² wafer with adhesion Low to moderate drianage
carboxyl methylcellulose; pectin gel atine;
impermeable to oxygen 
""#&& #& ² composite pads Low to heavily draining wounds
with collagen component 
c#  , "&& #& ² contain Infected or clean wounda to prevent
components infection
silver or iodine in various preparations 
" # ² amorphous hydrogels; skin Clean or infected wounds
cleansers 
#0)& ² collagenase, papain- urea, etc.  Necrotic or escharotic wounds

DEBRIDEMENT OF THE WOUND

þ Debridement may be considered one of the most important aspects of diabetic

foot ulcer care, along with offloading and infection control. The guidelines
recommend debridement of abscessed tissue along with incision and drainage.
þ Debridement is µthe removal of necrotic tissue to decrease the risk of infection
and to promote wound closure.¶
þ Debridement should remove all necrotic tissue, callus, and foreign bodies down
to the level of viable bleeding tissue. Wounds should be thoroughly flushed with
sterile saline or a noncytotoxic cleanser following debridement.
þ Hydrotherapy is not recommended for diabetic patients. Debridement is essential
for the removal of nonviable cells and for healing. ?eri wound callus must also
be removed, as it may contribute to periwound pressure and incomplete wound
contraction. Ulcers may also be obscured by the presence of callus.
þ Vascular status must always be determined prior to sharp surgical debridement.
This may be accomplished through techniques described earlier in this
manuscript. Determining local perfusion is of particular importance when deriding
ulcers on the distal aspect of the foot.
þ Debridement is contraindicated in patients with significant vascular compromise,
without healing potential, or when they are placed at greater risk.
þ Debridement of dry eschar in the comprom ised patient may not be necessary.
Special considerations include inadequate blood flow, immunosuppressive
therapies, poor nutrition, inadequate diabetes control, and high levels of
anticoagulants.
þ Consideration of risk versus benefit must be made in case s where deeper
structures, such as tendon, bone, or capsule, may be exposed as a result of
debridement. Clean, granulating wounds should not be derided.
þ Enzymatic debridement may be considered when sharp surgical intervention is
not an option.
þ Enzymatic debridement may be slow and ineffective where thick dry eschar is
present. Enzymes will not debride the periwound callus.
þ Autolytic debridement through accumulation of exudates under occlusion is not
recommended in diabetic patients as the pooling of fluid promotes bacterial
proliferation, which may place the diabetic patient at increased risk for infection.

CONTROL OF BLOOD SUGAR AND ANTIBIOTIC THERA?

þ Blood glucose level should be controlled by use of insulin in the various forms.
This is needed to provide good wound healing and tissue regeneration.
þ In the absence of diabetes, an individual cellular immune response results in
prolonged macrophage activity in a moist environment. Increased moisture
may promote autolysis without increasing the risk of infec tion. In persons with
diabetes and other individuals with a compromised cellular immune response,
pooling of fluid may promote colonization leading to infection.

þ Limb-threatening diabetic infections are usually polymicrobial involving

multiple aerobic and anaerobic infections. Staphylococcus aureus,Ybeta-
hemolyticYstreptococcus, Enterobacteriaceae YBacteroides fragilis,Y
?eptococcus, andY?eptostreptococcus may be culturedYfrom diabetic ulcers.
Malodorous wounds are likely to harbour aerobic and anaerobic organisms.
þ Choice of antimicrobials in the treatment of a limb -threatening diabetic foot
ulcer infection should include those with activity against Gram -positive and
Gram-negative organisms and provide aerobic and anaerobic coverage .
þ The patient's overall wound and medical status as well as the patient's
medical history determine the choice of oral versus intravenous antibiotics
and the need for hospitalization.
þ Clinicians may not have the luxury of awaiting culture or biopsy resul ts prior to
determining antibiotic choice. Treatment may be changed when dictated by
the culture result or when the patient is not responding to treatment. Cultures
are most reliable when a deep tissue specimen is obtained.
þ All organisms recovered from de ep tissue cultures should be treated as
pathogens unless there is evidence to support that the culture was
contaminated from another source. Swab cultures usually grow out numerous
surface contaminants and may not provide information on the pathogen(s)
causing the deep tissue infection. The rapid deterioration of an infected
wound in the diabetic patient necessitates immediate action by a clinician to
prevent amputation and other complications.
þ Topical antibiotics and antimicrobials are not indicated for th e treatment of a
deep tissue or bone infection.
þ Topical agents may reduce colonization in the wound, thereby reducing the
risk of infection. Topical antimicrobials have neither been proven to eradicate
an infection nor to be effective in the treatment of an infection. The primary
line of therapy for infection is the use of oral or systemic antibiotics. It is the
responsibility of the clinician to differentiate between contamination (the
presence of organisms in a wound), colonization (the multiplication of
organisms), and infection (the presence of greater than 1 x 10 5 organisms per
gram of tissue).
 þ Diagnosis of an infection should be based on clinical findings. Cultures are
meant to identify organisms and to assist in treatment of an infection rather
than be used to diagnose infection.
þ Antibiotics are known to be used indiscriminately and without need resulting in
an increased probability of developing resistance. The high morbidity and
mortality associated with infected diabetic ulcers suggest that the p rescription
antibiotics may be more appropriate when clinical signs of infection are
suspected in a diabetic ulcer than in wounds of other etiologies, with the
exception of immunocompromised patients. Treatment consists of appropriate
bandages, antibiotics (against staphylococcus, streptococcus and anaerobe
strains), debridement and arterial revascularisation.
þ It is often 500 mg to 1000 mg of flucloxacillin, 1 g of amoxicillin and also
metronidazole to tackle the putrid smelling bacteria.

AM?UTATION:

þ Any discussion of the diabetic foot requires introduction of the concept of

function-preserving amputation surgery. ?artial and whole foot amputations
frequently are necessary as treatment for infection or gangrene. The goal of
treatment is the preservation of function, not just the preservation of tissue.
Amputation surgery should be the first step in the rehabilitation of the patient.
Because most of these individuals are ambulatory, surgical planning should
be directed at the creation of a load -bearing terminal end organ that can
interface most easily with accommodative footwear, a prosthesis, or a
combination of both (ie, prosthosis). The principles that direct construction of
a residual limb for weight bearing with a prosthesis should be employed when
performing debridement or partial foot amputatio n.
þ The major value of partial foot amputation is the potential for the retention of
plantar load-bearing tissues, which are uniquely capable of tolerating the
forces involved in weight bearing. The soft-tissue envelope should be capable
of minimizing these forces. Avoid the use of split -thickness skin grafts in load -
bearing areas. Deformity should be avoided as much as possible. Tendo -
Achilles lengthening should be used to avoid equinus deformity and increased
loading of the residual forefoot in partial foot amputations. Retention of a
deformed foot with exposed bony prominence leads only to decreased
walking ability and recurrent ulceration.

#" #

The client is treated with Inj. Humulin N 10 Units Before breskfast and meals. She is
also on T. Metformin 1 gm HS. The management done for here is wound
debridement. She is now treated with oral antibiotics Inj Amoxicillin 500 m g BD, Inj
Amikacin 500mg BD. The wound in the right leg is treated with Ointment silver max
and neomin and wet dressing done TDS.





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IN BOOK IN CLIENT
This will including cellulitis, septic arthritis, abscess and sinus Not in client
tract formation, osteomyelitis, gangrene, and charcot foot
disease with attention to the differential diagnosis of various
pathologic findings. 




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Follow the healthy eating plan that you and your doctor or dietitian
have worked out.

Be active a total of 30 minutes most days. Ask your doctor what

activities are best for you.

Take your medicines as directed.

Check your blood glucose every day. Each time you check your
blood glucose, write the number in your record book.

Check your feet every day for cuts, blisters, sores, swelling, redness,
or sore toenails.

Brush and floss your teeth every day.

Control your blood pressure and cholesterol.

Don¶t smoke.

%%

ë ß&$)!% #))1 Make sure the water is not too

hot by testing the temperature with your elbow. Do not soak your feet. Dry
your feet well, especially between your toes.
ë ')!%))$'%!&-&&-," &&-#&&-
""!&&-$*,"&1 Checking every day is even more important if
you have nerve damage or poor blood flow. If you cannot bend over or pull
your feet up to check them, use a mirror. If you cannot see well, ask someone
else to check your feet.
 ë
%)!&' # &)-!," ## )!%%)!&$#)$1
Do not put lotion between your toes.
ë "#&#""!&&#") $#),*! &#1 Do
this after your bath or shower.

ë !)!# "&#'$##1 Cut toenails when they

are soft from washing. Cut them to the shape of the toe and not too short. File
the edges with an emery board.
ë c")&&" **&&$&*)!%% #2! &1

Always wear slippers or shoes to protect your feet.

ë c")&&'&&' #& ," &&1 Do not wear socks or

knee-high stockings that are too tight below your knee.
ë ß&$&$% ""1 Shop for shoes at the end of the day when your
feet are bigger. Break in shoes slowly. Wear them 1 to 2 hours each day for
the first few weeks.
ë %*! #)!&$&#-%"$ #& &'&!$)$#
&$*&,2&$ $ #2! )!%1

! " #&% 

?rotect your feet using the guidelines below.

Check your feet. Look at the tops and bottoms of your feet at the end of each day to
make sure you have no reddened areas, cuts, or scrapes that could become
infected.
Bathing and drying:

* Use warm (not hot) water to wash your feet. Then dry your feet carefully, especially
between the toes. Apply cream or lotion after your feet are dry to keep the skin soft
and free of dry skin.
* If your feet sweat a lot, keep them dry by dusting with talcum powder.

Treating corns and calluses:

* Tell your doctor right away if you develop a corn or callus.

* Don't treat corns or calluses yourself. Ask your doctor about using over -the-counter
products for these problems.

Toenail care:

* Cut your toenails carefully, cut or file your nails straight across and then use an
emery board to smooth the sharp corners. Do not cut the sides or the cuticles.
* Clean your nails carefully.
* If your nails are thick or ha rd to cut, ask your doctor's office for help.

Foot warmth:

* Wear cotton socks to bed if you need extra warmth for your feet.
* Avoid using hot water bottles or electric heaters to warm your feet. Because you
may not fully sense hot and cold with your f eet, you may burn your feet accidentally
and develop an infection.
* Avoid putting your feet where they could accidentally be burned; for example, on
hot sand at the beach, in hot bath water or whirlpools, or near a fireplace. Use
sunscreen on the tops of your feet.
Footwear:

* Take your shoes and socks off at each visit to your provider so that the doctor can
easily look at your feet.
* Wear shoes at all times, even in your house, at the beach or by a pool.
* Wear comfortable shoes that fit well. Change to a different pair of shoes at least
once during the day.
* Ask your doctor about specially made shoes, especially if you have foot problems.
* Avoid wearing new shoes for more than an hour a day until they are thoroughly
broken in.
* Avoid tight-fighting shoes, socks and hose.
* Wear clean socks and change them at least once a day.

In addition to these foot care guidelines, keeping your blood sugar and your blood
pressure close to normal helps prevent foot problems.