diabetic foot
Introduction
Introduction to Diabetic Foot Diabetic foot refers to the disease state in which the lower limb protection function is reduced due to neuropathy in the foot of diabetic patients, and the disease of ulcer and gangrene is caused by microcirculation disorder caused by insufficient perfusion of arteries. The diabetic foot is a serious complication of diabetes. It is one of the important reasons for the disability and even death of diabetic patients, which not only causes pain to the patients, but also adds a huge economic burden. basic knowledge The proportion of illness: 0.02% Susceptible people: no specific population Mode of infection: non-infectious Complications: frostbite, diabetes, gangrene
Cause
Diabetic foot cause
Ulcer (20%):
Many foot complications in diabetic patients result from sensory neuropathy and mild autonomic and motor neuropathy. Among them, sensory neuropathy combined with excessive mechanical stress is the main initiating factor causing foot ulcers and infections. Inflammation and tissue damage are the result of a certain degree of repeated stress acting on a particular area that loses sensation. Pressure or shear from the ground, shoes or other adjacent toes causes ulceration, which is often exacerbated by the presence of bony due to the lack of normal neuroprotective mechanisms. The autonomic nervous system lesions cause normal skin perspiration regulation, skin temperature regulation, and loss of blood regulation, resulting in reduced local tissue flexibility, thick sputum formation, and more fragility and cracking. In addition, the loss of normal wicking ability blocks the rehydration of local tissues, causing further destruction of the tissue, making the deep tissue more susceptible to bacterial colonization. Motor neuropathy also plays a role in the pathogenesis of diabetic foot, and the contracture of the internal muscle of the foot causes a typical claw-toed deformity. Over-extension of the metatarsophalangeal joint has also been shown to directly increase the pressure on the humeral head, making it more susceptible to ulcer formation. The proximal toe joint flexion causes an increased risk of ulceration of the dorsal joint of the interphalangeal joint and the metatarsal tip, and vascular lesions make the damaged tissue difficult to heal.
Infection (30%):
Autonomic dysfunction leads to destruction of skin and soft tissue, causing invasion of foreign bacteria. Changes in chemical tropism lead to inefficient white blood cell responses. In addition, hyperglycemia, decreased oxygen partial pressure, and malnutrition can collectively trigger tissue edema, acid accumulation, hypertonicity, and inefficient anaerobic metabolism. This type of environment is suitable for bacterial growth and hinders the function of white blood cells. In addition, vascular disease can cause restricted transport of antibiotics, further reducing the efficiency of bacterial clearance, leading to local soft tissue infections and even the formation of osteomyelitis.
Charcot arthropathy (10%):
For progressive weight-bearing joint destructive lesions. Neurotrauma theory believes that loss of pain and proprioception after repeated mechanical damage or single trauma can lead to Charcot joint disease. Neurovascular theory believes that increased blood supply in the lesion area caused by autonomic dysfunction leads to bone resorption and The strength is weakened, and in turn, repeated trauma causes bone destruction and instability.
Toe deformity (30%):
Motor neuropathy causes contracture of the intrinsic muscle of the foot, resulting in a typical claw toe deformity.
Prevention
Diabetic foot prevention
Principles of prevention and care of diabetic foot
After the diagnosis of diabetes, the first priority should be to actively control diabetes, strict control of hyperglycemia (including rational distribution of diet and hypoglycemic drugs and insulin application), while controlling hyperlipidemia and various factors leading to early arteriosclerosis, should be used as a preventive diabetes The long-term task of gangrene of the extremities makes the patient's blood vessels and neuropathy develop slowly, lighter, less, and carefully care for and prevent possible lesions in the foot. Therefore, it is necessary to:
1. First of all, we must pay enough attention from the thoughts, and regard foot care as an integral part of life and prevent it from happening.
2. Develop good foot hygiene habits.
(1) Wash your feet with warm water or soft soap every day to keep your feet clean.
(2) Test the water temperature by hand before washing the feet (the water temperature is suitable for putting the water on the skin of the back of the hand). It is absolutely not possible to use hot water to soak the feet and cause burns to avoid skin damage.
(3) After washing the feet, dry them with a dry towel, including the toes, and do not rub them with a coarse cloth to cause skin abrasions.
(4) To protect the skin from softness and cleft palate, apply skin oil, cream, cream, but do not apply it to the toe.
(5) It is not advisable to use talcum powder for water absorption for a long time. In order to prevent the pores from being blocked, it is not suitable to wear airtight nylon polyester socks. Cotton yarn socks or wool socks should be worn.
(6) Check the heel, sole, toe seam, whether there are ulcers, cracks, abrasions and blisters, etc. If you find a foot lesion, you should seek medical advice promptly, properly handle it, and do not wait for it, and delay treatment. opportunity.
(7) Corns, cockroaches can not be cut by themselves, nor can they be corroded with chemicals, and should be treated by a doctor.
(8) Shoes and socks should be suitable, loose, change socks every day, it is best to have two pairs of shoes to replace, so that the shoes remain dry, before the shoes should be checked for sand particles, nails and other debris in order to avoid the soles of the feet Broken.
(9) It is not advisable to wear pointed shoes, high heels, sandals with exposed toes and heels, and avoid walking barefoot or wearing slippers.
(10) Avoid using hot water bottles, kettles or electric blankets during cold winter to avoid burns on the feet.
(11) The cleft palate is not covered with tape, and the fungal infection of the foot should be treated in time.
(12) Avoid alcohol and tobacco, which is beneficial for the prevention and treatment of blood vessels and neuropathy.
(13) Try to avoid foot injury, prevent frostbite, crush, and choose appropriate physical exercise programs to minimize the risk factors of injury.
Complication
Diabetic foot complications Complications, frostbite, diabetes, gangrene
When the condition is serious, the skin may be ruptured, the tissue may be eroded until necrosis, or the skin may be numb or the feeling disappears, and the feeling of overheating or cold objects may be insensitive, resulting in burns or frostbite.
Diabetes combined with extremity gangrene is a clinical manifestation of chronic, progressive acral ischemia, pain, numbness of the hands and feet, and ulceration. The main causes are large, small, microcirculatory lesions, peripheral neuropathy and various injuries. Caused by a combined infection.
Symptom
Diabetic foot symptoms Common symptoms Acrom is easy to occur... Finger toe dry necrosis Abdominal ischemic vesicular edema Diabetes toe end dry black chronic ulcer Diabetic foot lesions
Clinical manifestations of diabetic foot: The clinical manifestations of diabetic foot patients are associated with five facial lesions: neuropathy, vascular disease, biomechanical abnormalities, lower extremity ulcer formation, and infection.
(1) General performance of the foot:
Due to neuropathy, the affected limb has dry skin without sweat, tingling, burning, numbness, feeling slow or loss of the extremities, a sore-like change, a cotton sensation on the foot; malaise due to acromegaly, muscle atrophy, flexor and extensor Loss of normal traction tension balance, causing the bone to sag and causing the interphalangeal joint to bend, forming a deformed foot such as a bow-shaped foot, a toe-like toe, and a chicken toe. When the patient's bones and joints and surrounding soft tissue strain, the patient continues to walk and easily cause bone and joint and ligament damage, causing multiple fractures and ligament rupture, forming Charcot. X-ray examination has bone destruction, and some small bone fragments are separated from the periosteum to cause dead bones to affect gangrene healing.
(2) Main manifestations of ischemia:
Common skin dystrophy Muscle atrophy, skin dryness and elasticity are poor, the hair is detached, the skin temperature is lowered, there is pigmentation, the arterial pulse of the extremity is weakened or disappeared, and the blood vessel stenosis can be heard. The most typical symptoms are intermittent claudication, rest pain, and difficulty in standing up. When the patient's affected limb has broken skin or spontaneous blisters, it is infected, forming ulcers, gangrene or necrosis.
(3) Diabetic foot ulcer
According to the nature of the lesion, it can be divided into neurological ulcer, ischemic ulcer and mixed ulcer. Neuropathic ulcers: Neuropathy plays a major role in the cause and blood circulation is good. This foot is usually warm, numb, dry, painless, and the foot arteries fluctuate well. Neuropathic feet can have two consequences: neuropathic ulcers (mainly in the soles of the feet) and neuropathic joints (Charcot joints). Foot ulcers caused by simple ischemia, no neuropathy, are rare. Neuro-ischemic ulcers These patients have both peripheral neuropathy and peripheral vascular lesions. The dorsal artery undulation disappeared. These patients have a cold foot that can be accompanied by pain during rest and ulcers and gangrene at the edges of the foot.
The site of foot ulcer is more common in the forefoot, often caused by repeated mechanical stress. Because the protective sensation caused by peripheral neuropathy disappears, the patient can not feel the abnormal pressure change, and can not take some protective measures. Concurrent infection, ulcers are not easy to heal, and finally gangrene occurs.
(4) Classification of diabetic foot:
The classic classification method is the Wagner classification method: level 0: there is a foot that is at risk of foot ulcers, and there is no open lesion in the skin. Grade 1: There is ulcer on the surface and there is no clinical infection. Grade 2: Deeper ulcer infections, often associated with soft tissue inflammation, no abscess or bone infection. Grade 3: Deep infection with bone tissue lesions or abscesses. Grade 4: bone defect, partial toe, foot gangrene. Level 5: Most or all of the feet are gangrenous.
Examine
Diabetic foot examination
Check the body
A thorough examination of the lower part of the lower extremity knee joint should be performed. Physical examinations should be conducted at least once a year and should be more frequent for high-risk groups. Problems that need to be observed and recorded include: abnormal gait, wear of the shoes, and the presence or absence of foreign objects protruding into the interior of the shoe, pulsation of the blood vessels, hair growth, skin temperature and capillary refilling, observing deformity and tissue destruction of the foot and heel. The location and size of the ulcer, the presence of edema or inflammation. Also check the stability of the joints and the strength of the muscles.
2. Comprehensive neurological examination
Inspection of reflection, motion and sensory functions. Qualitative sensory examinations such as light touch, two-point discrimination, acupuncture and proprioception. Quantitative sensory examinations, most often using Semmes-Weinstein nylon monofilament for pressure testing.
3. Vascular examination
The most common non-invasive test is arterial Doppler ultrasound. The data is represented by absolute pressure or - index. A - index of 0.45 is considered to be the minimum value at which the wound can heal after amputation. The absolute value of the toe vascular pressure of 40 mmHg is the minimum standard for wound healing. Note that patients with atherosclerotic disease may have a false increase in pressure. Other vascular examinations include determination of skin perfusion pressure and transcutaneous oxygen partial pressure. The former is the minimum pressure required to block the refilling of the skin after it has been compressed. The latter can also be used to determine the potential for healing after amputation. A pressure of less than 20 mm Hg has a high risk of wound infection, while above 30 mm Hg indicates sufficient healing potential.
4. Laboratory inspection
Blood sugar control is very important in the care of diabetic foot. If the metabolic control of diabetes is poor, there is a higher risk of ulceration. If hemoglobin A1c (glycated hemoglobin) is elevated, the ulcer healing time is prolonged and the likelihood of recurrence increases. Changes in these indicators predict patient compliance and healing optimization. In addition, serum total protein, serum albumin, and total lymphocyte count should also be examined. The minimum value for tissue healing is: serum total protein concentration is higher than 6.2 g / dl; serum albumin level is higher than 3.5 g / dl; total lymphocyte count is greater than 1500 / mm3.
5. Imaging examination
Ordinary X-ray is a first-line diagnostic test used to evaluate stress fractures, fractures, osteolysis/bone destruction, dislocation, subluxation, and changes in the bone structure of the foot and ankle; CT is used to assess details and changes in cortical bone The effect is better, such as assessing the healing of postoperative fractures or fusions. In addition, CT can also be used to assess soft tissue diseases such as abscesses; MRI is very sensitive to soft tissue and bone tissue changes caused by various causes, such as stress fractures, abscesses, osteomyelitis or neurological joint disease. However, it is difficult to distinguish Charcot joints from osteomyelitis. Both lesions have bone marrow edema and erosion-like changes.
Diagnosis
Diagnosis of diabetic foot
diagnosis
Diagnosis can be based on medical history, clinical symptoms, and laboratory tests.
1. Symptoms: In the early stage of the disease, the patient often has itchy skin, cold limbs, feeling dull, edema, followed by continuous numbness of the double-legged sock. Most of the pain may be reduced or disappeared, and a small number of needles appear in the affected area. Knife cuts, burning pain, increased at night or when hot, duck walking or leaning on the stick, some elderly patients with a history of severe limb ischemia, such as intermittent claudication, rest pain.
2. Signs: The patient's lower limbs and feet are dry, smooth, edematous, the hairs fall off, the lower limbs and feet become smaller, and the skin can be seen with scattered blisters of varying sizes, blemishes, ecchymoses, pigmentation, and cold extremities. When raising the lower limbs, the feet are white; when drooping, it is purple-red, toenail deformation, thickening, brittleness, shedding, muscle atrophy, poor muscle tone, common foot deformity, humeral head depression, metatarsophalangeal joint bending It has a bow-shaped toe-like toe, the toe is overextended like a claw, and the dorsal artery is cyanotic when the dorsal artery is occluded. The pulsation is very weak or disappears. Sometimes, the vascular murmur can be heard in the stenosis of the blood vessel, and the extremity feels dull and disappears. The tuning fork vibrates and the Achilles tendon is weak or disappears.
In the chronic ulcer of the foot, a round penetrating ulcer forms in the ankle and humeral head, sometimes ligament tear, small fracture, bone destruction, and Charcot joint, dry gangrene, all Feet, toes dry, smaller, skin bright, thin, reddish, there are a number of black spots in the edge of the toe, black spots, wet gangrene, redness, swelling, skin ulceration, formation Ulcers or abscesses of varying sizes and depths, skin, blood vessels, nerves, and bone tissue necrosis.
3. Clinically, according to the degree of diabetic foot lesions, it is divided into 6 grades.
Differential diagnosis
Need to be diagnosed with lower extremity vasculitis or vasculitis, lower extremity neuropathy.
True vasculitis: thromboangiitis obliterans, vascular tube inflammation is the abbreviation of thromboangiitis obliterans, is a kind of chronic occlusive disease of the middle and small arteries, and its pathological changes are medium and small arterial wall Segmental, non-suppurative inflammation with intravascular thrombosis, luminal occlusion caused by distal limb ischemia and pain, the main features of this disease are: (1) the disease mostly occurs in male young adults; (2) The limbs, especially the toes, are cold, cold, numbness and paresthesia are common early symptoms; (3) Pain is the main symptom of the disease, manifested as: 1 intermittent claudication: when the patient walks for a long distance, calf or foot Muscle numbness, soreness, pain, convulsions, weakness and other symptoms, if you continue to walk, the symptoms are aggravated, and finally forced to stop, after standing for a while, the pain is relieved quickly, you can continue to walk, but after walking, the above symptoms are repeated Now, this symptom is called intermittent claudication. It is a typical manifestation of insufficient blood supply to the lower extremity arteries. 2 Resting pain: When the arterial ischemia is severe, the pain of the affected limb is severe and persistent. The pain is still not enough at rest. It is difficult to stay through the night. And even toe ulceration infection, pain is more intense.
"Vasculitis" in the elderly: lower extremity arteriosclerosis obliterans, lower extremity arteriosclerosis obliteration is not vasculitis, it is a manifestation of systemic arteriosclerosis, is one of the common vascular diseases in the elderly, its pathological features The abdominal aorta, radial artery, femoral artery, radial artery and other large and medium-sized arteries thicken and harden, form atheromatous plaque and calcification, and secondary thrombosis, leading to narrow or occluded arterial lumen, manifested as Vasculitis is similar to the symptoms of lower limb ischemia, so it is often mistaken for vasculitis. In many cases, elderly patients have lower extremity pain, muscle aches and weakness, can not walk normally (ie intermittent claudication), etc., often thought to be bone Hyperplasia, osteoporosis, lumbar disc herniation, rheumatism, etc., took a lot of drugs for a long time, did not go to the hospital to see a specialist in time, and even some patients were delayed by the timing of the visit and forced amputation.
Diabetes foot gangrene and other gangrene identification points: gangrene is the death of tissue cells, the cause is often divided into circulating gangrene, such as atherosclerotic gangrene, embolic gangrene, thromboangiitis obliterans, Raynaud's disease, etc. Gangrene, neurotrophic gangrene, diabetic gangrene, mechanical, physical, chemical, injury and infectious gangrene, diabetic foot gangrene, from the pathological changes and the nature of gangrene, the degree is difficult to distinguish from other gangrene, Especially in middle-aged and elderly patients with atherosclerotic gangrene, it is more difficult to distinguish, but patients with diabetic foot gangrene have severe vascular disease, rapid progression of the disease, often accompanied by peripheral neuropathy and infection, and clinically It is often encountered that the gangrene of the foot does not heal for a long time, and cases of diabetes are found only during the examination. It is necessary to pay attention to the analysis of the occurrence of gangrene, whether it is accompanied by morbidity or comorbidity.
