Alarm Features starring the High Risk Diabetic Foot

Sue RobbPodiatrist

Foot Health Service West Hertfordshire Community Health Services

in 5

minutes!?

The Diabetic Foot – when to refer

• QOF screening – Who is high risk?

• Alert! ] refer to Foot Health Service

• Alarm ! ] urgent referral, & include Foot Health Service

Risk features of neuropathic foot• Warm foot, well-perfused,

bounding pulses, distended veins due to a-v shunting

• Sweating i skin dry/fissured

• Distal (below knee) symmetrical sensory loss

• Deformity, flexed toes, high arch, prominent met heads

• High pressure points a callus

QOF points

Neuropathic ulceration• Plantar metatarsal heads,

apecies of toes• High vertical pressures • Ulcer covered/surrounded by

callus, macerated by discharge

• Usually painless – pain first sign infected

• Good circulation – necrosis develops secondary to infection

Charcot arthropathy

Neuropathic osteoarthropathy - non infective destruction of bone

Affects patients with neuropathy

Acute phase mimics infection Casting stabilisation / non-

weight bearing essential Weight bearing e ‘bag of

bones’ appearance e ulcer from deformity

Neuroischaemic foot

• Atrophic thin frail shiny skin

• Diminished/absent foot pulses• Pallor on elevation• Rubor on dependency due to

capillary dilatation

• Intermittent claudication / rest pain, yet may be pain free

• Unforgiving foot

QOF points

Neuroischaemic ulceration• Ulcers on margins of feet

associated with trauma and fragile micro circulation

• Thin glassy callus or no callus

• First sign? - skin discolouration that blisters

• Pain may be due to infection or ischaemia

Identify high risk at screening

• High risk - presence of any risk factor for ulceration.

• Refer to FHS + continue screening

Risk factors for ulceration are 1. Previous ulceration /

amputation2. Neuropathy3. Absent/diminished pulses4. Deformity / LJM5. Callus6. Oedema7. Visual loss8. Self neglect / disability

No risk factors for ulceration = Low current risk Foot care education + annual screening. No FHS ref

Infection

<OsteomyelitisLook for signs of response to t/t in 3 days

callus

Sausage shaped toes“Beef chipolatas”Probe to bone

Pre ulcerative

Prevention of diabetic foot ulceration

• Good glycaemic control essential• Education – improve foot care knowledge

and behaviour• Daily foot check• Appropriate footwear• Timely vascular intervention• ‘High risk’ patients referred to Foot Health

Service

‘Team’ working prevents problems

• Early recognition and referral of the ‘at risk’ foot• Early detection and referral of ulceration,

Charcot, severe infection, acute/critical ischaemia• ‘Shared care’ programme – diabetes team, GP, nurse, podiatry and patient

Thank you for listening ……

Useful websites –www.diabeticfootjournal.co.uk

www.footindiabetes.orgwww.feetforlife.org