Diabetic Foot Ulceration

complication 

Wounds can deteriorate rapidly; they can become quickly infected leading to the rapid loss of tissue. Swift intervention is required in these circumstances to ensure the best outcome for the patient. NICE (NICE NG19) guidelines recommend referral to the specialist MDT within 24 hours.

The presence of diabetes can mask the signs of infection. Patients suffering with neuropathy are often unable to feel the pain of an ulceration or infection and present to clinicians late. Ultimately this can lead to osteomyelitis, sepsis, gangrene and, in the extreme, amputation.

 

Charcot


Charcot Neuro-arthropathy (Charcot) is a severe complication of diabetes. This condition can, at its extreme, result in amputation. It occurs in patients with neuropathy, the most common being in conjunction with diabetes.


Charcot presents as a red, hot, swollen foot and can be easily mistaken for a DVT or infection. The patient may or may not complain of pain in the foot. However, any new pain in conjunction with a hot, red or swollen foot should be strongly suspected of being a Charcot (in the absence of any signs of infection). The condition is characterized by progressive fractures and destruction of the bone and joints. As the patient has an insensate foot they will continue to walk on the affected limb, thereby leading to increasing destruction of the bones and joints. The foot can then destabilize and result in severe deformity including a rocker bottom foot.


Initial X-ray may not show any obvious signs, which is why it is imperative that serial X-rays are taken if there is any indication that a Charcot may be present. An MRI scan should also be considered.


The condition should be managed by the specialist diabetic foot team including the specialist orthopedic surgeon. The foot should be immediately immobilized, which may include a total contact cast with or without an off-loader, or with a removable walker boot. The foot should be immobilized until the inflammation has subsided, which can take 9 months or more. The aim of the immobilization is to preserve the architecture of the foot. If deformity has occurred further corrective surgery may be required to remove any bony lumps that may be predispose the patient to ulceration. Once the condition has resolved the patient may need ongoing total contact insoles and bespoke footwear.