Management of diabetic foot

Assess:

• neuropathy - check sensation (vibration sensation of reduced) in 'stocking' distribution; other possible features include absence of ankle jerks, foot deformity (claw toes, pes cavus, loss of transverse arch, rocker-bottom sole)
• ischaemia - clinical assessment and dopplers
• bony deformity assessed clinically and via Xray e.g. Charcot joint
• infection - consider swabs, blood culture, assessing ulcer depths via probe, Xray

Seek specialist advice early in the management of a diabetic foot.

The management of diabetic neuropathy is described in the linked item below.

Prevention is the most important aspect of treatment. The patient should pay close attention to choice of footwear and general foot care. Regular chiropody is required.

High-pressure areas are relieved via bed rest +/- use of therapeutic shoes; occasionally metatarsal surgery may be required. If there is ischaemia then wide-fitting shoes with deep toe boxes help to protect toes and vulnerable forefoot margins.

Control of infection - minor foot lesions should be treated with oral antibiotics (e.g. co-amoxiclav) and frequent topical antiseptic cleansing. If there is evidence of spreading infection or systemic involvement then the patient should be admitted to hospital for treatment. Treat fungal infections.

Maintain good glycaemic control.

Necrotic tissue removal - which varies form desloughing an ulcer to amputation.

Surgery is indicated if:

• there is evidence of severe ischaemia (e.g. rest pain, gangrene), or,
• there is deep infection or abscess formation, or,
• there is a spreading anaerobic infection, or,
• there is suppurative arthritis

The nature of the surgery (local excision and drainage or vascular reconstruction and/or amputation) is determined by factors such as general health of the patient, degree of peripheral vascular disease, the wishes of the patient as well as the presenting complication of diabetic foot.