Diabetic Foot Ulcers

In this episode of PodMD, Vascular & Endovascular Surgeon Dr Celina Kaiser will be discussing the topic of diabetic foot ulcers, including what foot ulcers are, causes of them, treatment options and more.

  • Transcript
    Please note this is a machine generated transcription and may contain some errors.
    *As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.

    Today I’d like to welcome to the PodMd studio Dr Celina Kaiser, who is a Vascular Surgeon

    She is skilled in classical open vascular surgery and minimally invasive endovascular techniques.

    Today, we’ll be discussing the topic of Diabetic Foot Ulcers.

    *We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD.
    If you do have a patient on whom you require specific advice, then please seek advice from a colleague with appropriate expertise in that area.

    Celina, thanks for talking with us on Pod MD today.

    Celina: Thank you for having me.

    Question 1
    The topic of today’s discussion is on Diabetic Foot Ulcers. Celina, can you describe for our listeners what Diabetic Foot Ulcers are?

    Celina: Diabetic foot ulcers are wounds or breaches of the skin in the feet of patients with diabetes, they are the result of repetitive trauma that wears a hole in the skin. This is an important topic as the vast majority of amputations in patients with diabetes are preceded By ulceration. Diabetic Foot Ulcers effect up to a quarter of diabetics in their lifetime. About 15% of these ulcers resulting amputation. Generally speaking, we classify these ulcers as aschemic neuropathic or a mix of the two or neuroischemic.

    Question 2
    What causes diabetic foot ulcers?

    Celina: Diabetic foot ulcers are the result of multiple factors apply such as peripheral neuropathy inpedivision, vascular disease. If we speak More in detail about peripheral neuropathy, we subdivide this in sensory neuropathy, motor neuropathy in autonomic neuropathy, speaking more in detail about sensory neuropathy. Patients with diabetes suffer these typical gloves and stalking Spartan sensory neuropathy, which leads to loss of protective sensation in the feet so much so that patients sustain repetitive unrecognized injuries to their feet that culminate in full thickness ulceration. These can go unoticed. Sometimes these patients may develop pain when deep sepsis or schemia develops. When we speak about modern neuropathy, we must speak about foot deformity, Which is a complication of diabetes. As modern neuropathy occurs later in the course of briefer neuropathy. It causes extensive changes in the biomechanics of the feet and lower limbs.

    And these changes of course alter the normal foot structure and the movement, the bony alignment and the balance of the extensor and flexor muscles all leading to shifts in the weight bearing area. So the foot and with time cause buildup and ulceration with regards to autonomic neuropathy, these causes, shunting of blood and loss of sweat and oil gland function, which results in dry skin that is prone to cracks and fissures and skin right down and additional risk factors, retinopathy that impairs these patient’s vision. So they’re unable to identify areas of risk or that have developed ulceration on their own feet. Also vascular disease, where else It’s microvascular disease or microvascular complications are prevalent in patients with diabetes and the healing process and capacity in patients with vascular disease Is impaired with all these factors that play Minor trauma. And this can sometimes be very innocent, like getting new shoes can rapidly evolve from a blister to deep ulceration that can threaten foot viability assessing the lower limb arterial tree. Clinically is a must in all patients presenting with a foot ulcer. And if pedal pulses are not present investigating with noninvasive scans, such an arterial ultrasound is appropriate.

    Question 3
    How would a diabetic patient initially present with their beginnings of foot ulcers.

    Celina: Initially they can present with callus buildup in the areas of the foot that are under higher sheer stress or increased pressure a callus is somewhat misleading. These lesions are formed of thickened hyperkeratotic compacted cells, and they don’t necessarily protect the tissues from pressure. In fact, they’re considered by many to be pre ulcerative lesions. The tissues under the callus can be under significant pressure, and it is when hemorrhage develops in the layers of the callus that the full-blown ulceration becomes evident in other occasions, mild erythema over bony prominences in the foot can be the precursor of ulcers. Sometimes these patients present with a blister or what looks like a blood blister that rapidly reveals itself to be a full thickness ulceration. And in other cases, an ingrown toenail, or a nail infection act as the precursor to an ulcer, some patients present with a foot ulceration as a first sign of undiagnosed diabetes.

    Question 4
    What is the most common symptom of foot ulcers and what should a GP look for?

    Celina: The majority of patients will present to their GPS when they notice a discharge from the foot or malorder, or when they’re systemically unwell without an apparent source. You know, the old adage prevention is better than cure rings particularly true in diabetic foot ulcers GPS of course play A central role in patient education and awareness and the integration of the multiple practitioners that are involved in a patient with diabetes, examining the feet of patients with diabetes, at least once a year or more often, if the patient has a higher risk of diabetic foot ulcers, as well as educating the patients to check their own feet every night. And look for skin breaches is fundamental examining for pulses in the lower limbs, particularly checking for desal speeders and posterior tibial pulses, also liaising and referring to a podiatrist for periodic assessments and offloading of pressure areas in the feet and an orthotist to aid in the shoe, selection and modification as needed, and then liaising with the vascular surgeon to assess the arterial supply of the lower limb as part of the chronic health management plan are all strategies to promote diabetic foot health.

    Question 5
    What initial investigations could a GP order for a patient for a patient with a diabetic foot ulcer?

    Celina: Starting with the basics such as blood workup, including FBE renal function, CRP also an x-ray of the foot looking for signs of osteomyelitis, collecting a swab, if there’s any exit egg present and sending these for MCNs. And just a note on the clinical examination that it’s worth noting that ankle-brachial indexes, although they are easily performed by the bedside, they may not be entirely reliable in this patient population. So we take these results in clinical context, absolute toe pressures are used much more commonly in these patient cohort to predict tissue healing and the podiatrist can help with obtaining this also, um, organizing for an arterial Doppler ultrasound, of the effected extremity, particularly if pulses are not palpable on clinical examination,

    Question 6
    How can you treat foot ulcers?

    Celina: The treatment of diabetic foot ulcers is multidisciplinary it’s individualized, and patient-centered ideally working on a preventative plan. And as part of the management of patients with chronic disease in the community, linking the patient with the podiatrist for regular foot assessments of floating areas risk, or that have active ulceration. An orthotist to advise on footwear modification strategies with the same aim and referring to a vascular surgeon to interrogate the lower limb arterial tree and address any lesions to aid in wound healing. Some patients will present to the consultation with a GP being systemically unwell, and the best option in these cases is for hospital admission, for hydration, antibiotic treatment investigating and addressing the vasculature and managing the wound with frequent dressings or operative intervention as needed. Of course, diabetes control with input from an endocrinologist is the standard as well as involving an infectious disease specialist to advice on the most appropriate antibiotic agent and duration of treatment.

    Question 7
    When should a GP refer?

    Celina: I would recommend referring a patient with a diabetic foot ulcer to a vascular surgeon for assessment on initial discovery of an ulcer or a wound or a blister that is not improving with simple dressings. Early referral is best to prevent extensive tissue loss and decrease the risk of requiring amputation.

    Concluding Question
    Thank you for your time here today in the PodMD studio. To sum up for us, could you please identify the three key take home messages from today’s podcast on diabetic foot ulcers?

    My three take home messages are:
    1. First patient education and awareness of foot health is the best prevention
    2. Treatment is multidisciplinary and refer early.
    3. A diabetic foot ulcers is a reflection of systemic disease and should not be considered trivial.

    Thanks for your time and the insights you’ve provided.

    Celina: Thank you for having me

*As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.