Decreased pulse of dorsal and posterior tibial arteries
Introduction
Introduction 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 the ulcer and gangrene is caused by microvascular dysfunction caused by insufficient perfusion of arteries. The back of the foot and the posterior tibial artery can be found. The pulsation weakens or disappears, the local skin is malnourished, the skin temperature is lowered, the color is abnormal, and the finger is pale when the gum is high, the drooping is purple-red, and the foot is prone to chronic ulcer. Diabetic foot is a serious complication of diabetes. It is one of the important causes of disability and even death in diabetic patients. It not only causes pain to patients, but also adds huge economic burden.
Cause
Cause
(1) Causes of the disease
The cause of diabetic foot is multifactorial. Diabetic neuropathy, peripheral vascular disease and microcirculatory disorder are the main causes, which may exist alone or in combination with other factors, such as foot structural malformation, abnormal gait, skin or toenail. Malformations, trauma and infection are also important causes of diabetic foot.
Diabetic vasculopathy and neuropathy are the basic causes of diabetic foot complication. Diabetic people's feet are particularly prone to vascular and neuropathy. Diabetic vascular and neuropathy affect each other and cause a series of clinical foot diseases, including toe disease and spasm formation. , skin damage and foot ulcers, musculoskeletal lesions cause foot deformation. People with diabetes are prone to trauma due to neuropathy, which often leads to loss or reduction of the foot. Mild trauma can quickly lead to ulcers, infections and gangrene, which eventually necessitates amputation. The incidence of diabetic foot is significantly increased, which is related to the following factors:
1 The increase in the number of patients with diabetes worldwide.
2 The life expectancy of diabetes is prolonged, and the duration of diabetes is also prolonged.
3 The increase in the aging population. The prevalence of diabetic foot varies from country to country, accounting for 6% to 12% of hospitalized diabetics. In the United States, there are more than 40,000 diabetic amputees per year. In fact, 50% of non-traumatic amputees are diabetics, and diabetics have lower extremity amputations. The risk is 15 times that of non-diabetics.
Pathogenesis of diabetic foot
1. Neuropathy-induced sensory disturbance is the basis of diabetes
The autonomic neuropathy of the limb blood vessels weakens the vascular motion, reduces the local tissue resistance, and causes microscopic wounds to cause infection. However, due to local sensory disturbances, the tiny lesions cannot be treated in time, leading to rapid expansion of the wound. At the same time, due to limb dysfunction, it is also easy to cause burns. Neuropathy can cause small muscle atrophy in the foot, resulting in claw-like toes (especially the third, fourth and fifth toes) due to the non-resistance of the long muscles. This deformity makes the humeral head a support point for the weight of the sole. Due to friction, there is a sputum formation, which is highly prone to infection and penetrating ulcers, and the severe spread to nearby bones causes osteoarthritis. Due to the deep feeling disappearance and the joint movement reflex disorder, some patients are unconsciously overloaded, and some protective effects on multiple repeated traumas are lost, making the joints and joint surfaces very irregular and prone to fractures. , joint dislocation and subluxation, especially the metatarsophalangeal joint.
2, arteriosclerosis of the lower extremities leads to foot ischemia, which causes diabetes to occur.
The arteriosclerosis of the lower extremities causes foot ischemia, especially the toes, plus small blood vessels and microvascular lesions, which causes the blood pressure of the toes to drop to half or less of the whole body blood pressure. Patients often get up when they are asleep at night due to toe pain and need to walk a few steps to ease. In some cases where it is necessary to rapidly increase blood circulation (such as trauma, infection, over-cooling and overheating), the blood flow cannot be increased correspondingly, which can cause gangrene, especially in the toes.
3, infection is the fuse that causes diabetic foot
Neuropathy and ischemia are prone to local trauma and secondary infection. In mild trauma such as pressure ulcers on the soles of the feet, toenail trimming is too short, and improper treatment of the ankle can cause secondary infection. In the skin pressure load site, the skin and subcutaneous fibrous adipose tissue can be thickened. Once the heel is infected, it is easy to spread to the surrounding area. The ligament trauma can spread the infection and cause osteomyelitis of the tibia. Wet, dry, and mixed gangrene occur depending on the degree of ischemia.
Risk factors for diabetic foot
(1) The course of diabetes is more than 10 years;
(2) poor long-term glycemic control;
(3) Poor health care for wearing inappropriate shoes and feet;
(4) The past history of foot ulcers;
(5) Symptoms of neuropathy (numbness of the foot, loss of sensation or loss of pain) or (or) ischemic vasculopathy (motion-induced gastrocnemius pain or chills);
(6) Signs of neuropathy (foot fever, skin not sweating, muscle atrophy, eagle-claw-like toe, thickening of the skin at the pressure point, good pulse, good blood filling) and/or signs of peripheral vascular lesions (foot Cool, thin and thin skin, loss of pulse and atrophy of subcutaneous tissue);
(7) other chronic complications of diabetes (severe renal failure or kidney transplantation, obvious retinopathy);
(8) The neurological and/or vascular lesions are not severe and there are severe foot deformities;
(9) Other risk factors (loss of vision, orthopedic problems affecting foot function such as knee, hip or spine arthritis, improper footwear;
(10) Personal factors (poor socioeconomic conditions, old age or living alone, refusal of treatment and care; smoking, alcoholism, etc.);
(11) Delay in diagnosis of diabetes.
The frequency of follow-up of diabetic foot should be based on the type and extent of the condition. For example, patients with ulcers on the soles of the foot should be diligently reviewed, and can be reviewed once every 1-3 weeks; patients with sensory loss of the foot can be reviewed every 3 months.
Classification and performance of diabetic foot lesions
The commonly used classification method is the wagner classification method, see the table below.
Graded clinical performance
Grade 0 has a foot that has a risk factor for foot ulcers and is currently free of ulcers.
Grade 1 surface ulcer, clinically free of infection.
Grade 2 deep ulcers, often associated with soft tissue inflammation (CELLULITIS), no abscess or bone infection.
Grade 3 deep infection with bone tissue lesions or abscesses.
Level 4 localized gangrene (toe, heel or forefoot).
Level 5 is all gangrene.
Grade 0: refers to the foot with high risk of ulcers. For those patients who currently have no foot ulcers, regular follow-up should be carried out to strengthen the education of foot protection. If necessary, please give specific instructions to the podiatrist to prevent the occurrence of foot ulcers. .
Grade 1: ulceration of the skin surface of the foot, clinically no infection. Highlighted as a neurological ulcer. This ulcer occurs well at the point of the foot, the pressure-bearing point, such as the heel, the foot or the toe, and the ulcer is surrounded by the sputum.
Grade 2: Deeper, penetrating ulcers, often associated with soft tissue infections, but without osteomyelitis or deep abscesses, there may be some special bacteria in the ulcer area, such as anaerobic bacteria, gas-producing bacteria.
Grade 3: Deep ulcers, often affecting bone tissue, and have deep abscesses or osteomyelitis.
Grade 4: characterized by ischemic ulcers, gangrene of local or specific parts of the foot. Usually combined with neuropathy. Gangrene without severe pain suggests neuropathy. The surface of necrotic tissue may be infected.
Level 5: Gangrene affects the entire foot. Aortic obstruction plays a major etiological role, as well as neuropathy and infection.
DUSS system: a new method for grading diabetic foot ulcers
Beckert et al., University of Tübingen, Germany, have proposed a new method for grading the severity of diabetic foot based on the nature of the ulcer. Accordingly, they established a new Diabetic Foot Ulcer Severity Score (DUSS) system, and applied this scoring system to evaluate 1000 patients, which proved that the scoring system can accurately predict the prognosis of patients with diabetic foot ulcer. [Diabetes Care 2006, 29(5): 988]
Although there are several recognized classifications of diabetic foot ulcers, there is still a lack of a scientific, accurate, and practical scoring system to assess the severity of diabetic foot and to judge prognosis.
The researchers used the DUSS system to evaluate 1,000 patients with diabetic foot ulcers and followed up until ulcer healing or amputation or one year. The results showed that the ulcer healing rate was significantly higher in the score of 0, while the ulcer healing rate was lower in the high score, and the amputation rate was higher. The ulcer healing rate was significantly different in different subgroups with the same score. Further analysis showed that for every 1 point increase in score, the ulcer healing rate was reduced by 35%. Similarly, the higher the score, the larger the initial ulcer area, and the longer the ulcer history, the greater the likelihood of hospitalization or surgery.
Research suggestion: The scoring system is simple and practical, and each doctor can easily apply the system to predict the prognosis of patients with diabetic foot ulcers, so that patients can be promptly treated by specialists.
Three signs of diabetic foot
Lower extremity vascular disease caused by diabetes
Chronic peripheral neurological complications in diabetic patients, especially sensory complications in diabetic patients, are associated with sensory loss or abnormalities. For example, the numbness of the end of the extremities, especially the sensation of the feet, the feeling of walking, like the cotton, or the acupuncture, etc., are all peripheral neurological complications of diabetic patients.
If the dorsal artery pulsation weakens or disappears (of course, the method we often use is to compare the two feet), then he may have foot lesions caused by diabetes, and should do a foot color B-ultrasound (Doppler examination). If the above-mentioned main blood vessels are blocked and huge plaques are formed, they can be diagnosed as diabetic foot.
Peripheral neuropathy caused by diabetes
Chronic peripheral vascular complications in diabetic patients, this peripheral vascular complication will have a series of early stages, due to the gradual stenosis of the vascular lumen, a series of clinical manifestations, including the numbness, pain, walking distance of the lower limbs of patients The shorter, we call intermittent claudication, or the patient feels pain, that is, when sitting still, early detection of neuropathy, mainly to see if there are pain, numbness, heat, tingling and other symptoms. You can do a nylon silk sensory examination and electrophysiological examination (doing the median nerve, the toe nerve, the anterior tibial nerve).
Diabetes-induced infection
On the basis of peripheral blood vessels and neurological complications, due to the ineffectiveness of protective measures, skin damage caused by wearing shoes, socks, and nails, etc., this series of problems is called diabetic foot.
(two) pathogenesis
1. Peripheral vascular lesions Compared with non-diabetic patients, the incidence of peripheral vascular disease in diabetic patients increased significantly. The lower extremity Doppler study reported that the incidence of peripheral vascular disease in diabetic patients was 2.5 to 3.0 times that of non-diabetic patients. The WHO Diabetes Complications Study from London reported that 3% of male diabetic patients and 0.5% of female diabetic patients were found to have intermittent claudication, and 13% to 20% of patients with diabetic foot ulcers showed lower extremity ischemia alone. 20% to 25% of peripheral arterial disease and neuropathy exist simultaneously, and 46% of amputations are associated with lower limb ischemia.
Peripheral vascular arteriosclerosis leads to ischemia of the lower extremities, and severe gangrene occurs. In addition to macrovascular disease in vascular lesions, small blood vessels and capillary lesions also have a very important role. Small vascular lesions showed thickening of the basement membrane, and poor vascular elasticity caused a decrease in the ability of the small arteries to compensate for dilation when the perfusion pressure was reduced, and the hyperemia reaction was weakened during local injury. Thickening of the basement membrane also prevents the migration of activated leukocytes to the tissue, which is prone to infection. Capillary structural abnormalities and sclerosis, combined with advanced functional abnormalities (impaired congestive response, increased arteriovenous shorts, and loss of self-regulatory function), aggravate tissue ischemia and hypoxia, promote tissue necrosis and ulceration, and often cause the foot to occur The ulcer does not heal for a long time.
2. Peripheral neuropathy Peripheral neuropathy includes somatic (sensory and motor) lesions and autonomic neuropathy. About 60% of patients with diabetic foot ulcers are generally reported to have neuropathy alone, and 25% are mixed with other factors. Sixty percent of patients with diabetic lower limb amputation are associated with neuropathy. In the somatic neuropathy, it is mainly sensory neuropathy, which leads to the loss or loss of pain, temperature, vibration and position. The sensory neuropathy loses the intact protective mechanism of the skin and increases the chance of foot injury (such as stab wounds and burns). , bruises and unconscious gait changes) and make the skin undetectable when small breakage or trauma occurs, inducing or triggering the onset of ulceration.
Motor neuropathy leads to disuse of small muscles, imbalance of flexor and extensor muscles, resulting in claw-like and humeral head protrusions, increasing the chance of skin abrasions; in addition, neuropathy caused by muscle atrophy and pressure Unbalance, often the patient's body gravity is concentrated in the humeral head, heel and sputum, and the formation of sputum increases the pressure load, which is easy to cause ulcer formation. Autonomic neuropathy reduces sweating of the lower extremities, dry skin is prone to rupture and fissures; in addition, autonomic neuropathy increases the arteriovenous short circuit and increases the total blood flow of the skin, resulting in an increase in skin temperature (often easy to give people the illusion: the foot The circulation is good and the risk is small. When the arteriovenous shunt is increased, the perfusion pressure of the toes and the capillary blood flow of the nutrient are reduced due to the phenomenon of "capillary stealing blood" and the hypoxic reaction is reduced when the injury is caused, thereby increasing the diabetic foot. Danger; in addition, blood flow increases and blood flow accelerates, bone resorption increases, causing joint collapse and foot deformity, the formation of new pressure points on the foot during walking, increasing the risk of ulcers.
3. Other risk factors Biophysical factors and trauma are often the cause of diabetic foot ulcers. Sometimes diabetic patients may walk on sharp foreign bodies without pain because of sensory disturbances in the feet, but more common are repeated small mechanical traumas. The friction between the unconscious toe and the shoes worn or the pressure on the toes during walking increases; the morphological changes of the diabetic foot cause the toes to protrude, the pressure on the soles increases, the pressure on the soles increases, and the glycation of the connective tissue of the joints increases. The movement of the joint is limited to a certain extent. The limited movement of the joint changes the mechanical landing point during walking, further increasing the pressure on the sole of the foot. Continued increase in the pressure of the sole is an important factor in the formation of diabetic foot ulcers; others are incorrect. Treatment such as "eye cream", improper repair of nails, etc. is also the cause of skin damage to the feet; infection is an important factor in the occurrence and deterioration of diabetic foot ulcers, due to skin trauma, systemic (cellular immunity, humoral immunity) And the reduction of neutrophil function, etc.) and the reduction of local resistance of the foot, almost all of the diabetic foot ulcers Infection, and often mixed infections of multiple strains, anaerobic bacteria are very common.
Examine
an examination
Related inspection
Posterior tibial muscle strength test
Clinical manifestations of diabetic foot: The clinical manifestations of diabetic foot patients are associated with five aspects of the disease: neuropathy, vascular disease, biomechanical abnormalities, lower extremity ulcer formation and infection.
(1) General manifestation of the foot: due to neuropathy, the affected limb is dry and sweat-free; the limb is stinging, burning, numb, feeling dull or lost, changing in a sock-like shape, feeling on the foot; Malnutrition, muscle atrophy, flexor and extensor muscles lose normal balance of traction tension, causing bones to sag and cause toe joints to bend, forming arch deformities such as arched feet, clubats, and claws. 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, poor skin dryness, hair loss, skin temperature drop, pigmentation, weakened or disappeared arterial pulse, vascular murmurs can be heard in stenosis. 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 ulcers can be classified into neurological ulcers, ischemic ulcers and mixed ulcers according to the nature of the lesion. 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.
3) Classification of diabetic foot: The classic classification method is Wagner classification method: 0: there is a foot with a risk of foot ulcer, 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.
In addition to routine physical examination, diabetic patients should pay special attention to the signs of the foot: such as the patient's walking gait, the presence or absence of foot deformities such as talc foot and toe valgus, muscle atrophy, paralysis; skin temperature, color And sweating, observe the skin has no blister, cracks and rupture; check the skin's feeling of temperature, pressure and vibration (tuning vibration); palpation of the dorsal artery with or without pulsation weakened or disappeared in the artery Vascular murmurs can be heard in the stenosis; careful examination of sputum reflections such as knee reflexes and tendon reflexes can be attenuated or disappeared.
1. Symptoms In the early stage of the disease, the patient often has itchy skin, cold limbs, slow feeling, edema, followed by continuous numbness of the double-legged sock. Most of them may have pain loss or disappear, and a few needle-like lesions and knives appear in the affected area. Cut, burning, pain, at night or when heated, the duck walks or walks against the stick. Some elderly patients have a history of severe limb ischemia, such as intermittent claudication and rest pain.
2. Signs of the patient's lower extremities and feet are dry, smooth, edematous, the hairs fall off, and the lower limbs and feet become smaller. The skin can be seen with scattered blisters, blemishes, ecchymoses, pigmentation, and cold extremities. When raising the lower limbs, the feet are white; when drooping, they are purple-red. Toenail deformation, thickening, brittleness, shedding, etc. Muscle atrophy, poor muscle tone. Common foot deformities, humeral head depression, metatarsophalangeal joint flexion, arched toe-like toe, toe overextension like claws. When the dorsal artery of the foot is occluded, the skin of the feet is bruising, the pulsation is very weak or disappears, and sometimes the vascular murmur can be heard at the stenosis of the blood vessel. The sensation of the extremities disappeared, the vibration of the tuning fork disappeared, and the Achilles tendon reflex was weak or disappeared.
When the foot is chronically ulcerated, a round penetrating ulcer forms on the ankle and the humeral head. Sometimes ligament tears, small fractures, bone destruction, and Charcot joints. When the dry gangrene is dry, the whole foot and the toes are dry and small, the skin is bright and thin, and it is light red. There are a number of black spots and dark spots in the edge of the toe. When wet gangrene, the feet are red, swollen, and the skin is ruptured, forming ulcers or abscesses of varying sizes and depths, and necrosis of skin, blood vessels, nerves, and bone tissue.
3. Clinically, according to the degree of diabetic foot lesions, it is divided into 6 levels, as shown in Table 1.
4. According to the local manifestations of diabetic foot lesions, it is often divided into three types: wet, dry and mixed gangrene. See Table 2, Figures 1-13.
(1) Wet gangrene: occurs mostly in younger diabetic patients. Due to the simultaneous obstruction of the arterial and venous blood flow and microcirculatory disorders, skin trauma, infection and disease. The lesions are mostly in the plantar area, the humeral head or the heel. The degree of disease varies from superficial ulcer to severe gangrene. Local skin congestion, swelling, and pain. Severe with systemic symptoms, elevated body temperature, loss of appetite, nausea, bloating, palpitations, oliguria and other bacteremia or toxemia.
(2) Dry gangrene: more common in elderly patients with diabetes. Atherosclerosis of the lower extremities, atherosclerosis of the extremities, stenosis of the lumen, thrombosis, occlusion. However, venous blood flow is not blocked. Partially manifested that the skin of the foot is pale and cool, and the toe area has black areas of different sizes and shapes, suggesting that the toe-end micro-arterial embolism and toe pain. Dry gangrene often occurs on the dorsal side of the toes and feet, sometimes the entire toe or foot becomes dark, dry, and small.
(3) Mixed gangrene: dry gangrene and wet gangrene are present in different parts of the same extremity. The scope of gangrene is large, involving most or all of the foot, and the condition is heavier.
1. Neuropathic diabetic foot manifests as local warmth, numbness, dryness, loss of pain, and arterial pulsation, which can lead to neuropathic ulcers (which occur mostly in the soles of the feet), Charcot's foot and neuropathic edema. The neuroischemic type showed a decrease in skin temperature, a decrease or even loss of arterial pulsation, rest pain, foot ulcer, and focal necrosis.
2. Both types of diabetes are prone to infection, ulcers often become the gateway to bacterial invasion, usually a variety of microbial infections, and quickly spread to surrounding tissues, eventually involving the whole body, tissue damage caused by infection is the main cause of amputation .
3. The key to diagnosing neuropathic and neuroischemic diabetic foot is the presence or absence of arterial pulsation. Therefore, the examination of arterial pulsations is very important, and this is the most easily overlooked. As long as the posterior tibial artery or the dorsal artery of the foot can be touched, the ischemia is not serious. If all disappears, it indicates a decrease in blood circulation. Measuring the pressure index ( systolic pressure / systolic pressure) is helpful in judging. In normal people, the ratio is usually >1, and in the case of ischemia, it is 1 to exclude ischemia. This has important reference value for clinical decision-making, because it means that macrovascular disease is not the main factor, so there is no need for angiography.
4. However, clinically, 5% to 10% of diabetic patients have elevated systolic blood pressure due to non-compressive peripheral vascular disease, which is still the case in the presence of ischemic lesions. Therefore, the diagnosis of diabetic foot with an arterial pulsation that cannot be reached and a pressure index greater than 1 is difficult. Sometimes, especially in the case of foot edema, the examiner fails to touch the original arterial pulsation. At this time, the body should be re-examined after Doppler ultrasound localization. If it is still not accessible, it may be the middle layer of the vessel wall. It should be considered that ischemia exists. . In this case, the blood flow rate of the Doppler ultrasound, the examination of the waveform, and the measurement of the pressure of the big toe are helpful for diagnosis.
5. For distal obstructive lesions, the Doppler examination showed abnormal waveforms, and the normal rapid systolic pulsation and diastolic flow disappeared. As the lesion accelerated, the waveform changed from flat to disappear. References for the severity of arterial lesions can be found in the relevant books.
6. The measurement of the systolic pressure of the big toe requires a special thumb socket and a device capable of measuring the blood flow of the toe, such as laser Doppler or plethysmograph. The hallux pressure 30 mmHg indicates severe ischemia and poor prognosis. In addition, the percutaneous oxygen partial pressure of the foot is measured.
7. The degree of neuropathy needs to check whether the acupuncture and cotton sensation and the vibration sense (using a 128cps tuning fork) are normal, check whether there is a symmetric distribution of sore-like peripheral neuropathy, if the knee and ankle joints are missing Indicates the presence of peripheral neuropathy. The examination of autonomic neuropathy is difficult, and can be judged based on whether there is dry skin, chapped or sweating abnormality.
8. Once the neuropathy is diagnosed, it is important to determine whether the patient's protective pain perception is present. If it does not exist, it is more likely to suffer from diabetic foot ulcers. Two clinically valuable methods of examination are: vibration measurement and nylon fibril examination. The vibration feel can be measured using a manual vibration threshold meter. It should be noted that the vibration threshold increases with age and its measurements must be corrected using peer data. Nylon filaments can measure the pressure perception threshold. If a linear pressure equivalent to 10 g is not felt, it indicates that the protective pain sensation disappears.
Clinical diagnosis and grading of diabetic foot: Diabetic patients who have been examined for extremity lesions can be diagnosed as diabetic foot. According to the extent of the disease and with reference to foreign standards, the diabetic foot is divided into 0 to 5 grades.
Grade 0: There is no open lesion in the skin. Often manifested by insufficient blood supply to the extremities, cold skin, purple color, numbness, stinging, burning, feeling slow or loss, and high-risk performance such as toe or foot deformity.
Grade I: Open skin of the extremities. Superficial ulcers caused by blisters, blood blister corns or blemishes, frostbite or burns and other skin damage, but the lesions have not affected deep tissues.
Level II: Infected lesions have invaded deep muscle tissue. There are often cellulitis multiple pus and sinus formation, or infection along the muscle space to enlarge the foot and foot back ulcer, more purulent secretions, but there is no tissue damage in the tendon ligament.
Grade III: Destruction of tendon ligament tissue, cellulitis fusion forms a large abscess, purulent secretions and necrotic tissue increase, but bone destruction is not obvious.
Grade IV: Severe infection has caused bone defects, osteomyelitis and bone and joint destruction or formation of pseudoarthrosis. Some of the fingers or parts of the hands and feet have wet or dry severe gangrene.
Grade V: Most of the foot or the entire infection or ischemia of the foot, leading to severe wet or dry necrosis. The extremities become black and dry, and often spread to the calf joints and calves. Generally, surgical high amputations are taken.
Diagnosis
Differential diagnosis
The ulnar artery or radial artery beats weakened and disappeared: the forearm artery mainly consisted of the radial artery, the ulnar artery and the interosseous common artery, and the palmar arch and the deep palm arch formed by the hand. Forearm arterial injury mainly manifests as partial obstruction of blood supply to the hand, including weakening and disappearance of ulnar artery or radial artery pulsation, cold finger sensation, skin irritation and numbness.
The dorsal artery pulsation disappears: lower extremity atherosclerosis is often accompanied by numbness of the extremities, and the pulsation of the dorsal artery of the foot disappears. The disease is more common in middle-aged and elderly people, often accompanied by a history of hypertension. The early symptoms are mainly intermittent claudication, and the pain at rest is the manifestation of severe ischemia of the lower extremities, often accompanied by numbness of the extremities. Acromegaly ulcers and gangrene can also occur in the advanced stage. Physical examination revealed a decrease in extremity skin temperature, a stenosis, or a weakening or disappearance of the distal arterial pulsation of the occlusion artery. Doppler ultrasound and angiography can be used to determine the location, extent and extent of the disease and contribute to the choice of surgical approach.
Arterial pulsation weakened or disappeared: the arterial position was deep, adjacent to the femur and the posterior part of the knee joint capsule. The outer edge of the semitendinosus muscle is obliquely outward, and the femoral condyle is horizontally located in the posterior middle of the knee, and then vertically descends to the inferior border of the muscle, which is divided into the anterior iliac artery and the posterior tibial artery. The former enters the anterior region of the calf through the upper edge of the interosseous membrane, and the latter passes through the deeper part of the soleus tendon to the posterior region of the calf. In addition to the distribution of muscle branches in the adjacent muscles, there are five joint branches, namely the internal and external laparoscopic arteries, the middle knee artery and the inferior and lateral arteries of the knee, all of which are involved in the formation of the knee arterial network. The upper part of the artery is closely related to the femoral surface.
Clinical manifestations of diabetic foot: The clinical manifestations of diabetic foot patients are associated with five aspects of the disease: neuropathy, vascular disease, biomechanical abnormalities, lower extremity ulcer formation and infection.
(1) General manifestation of the foot: due to neuropathy, the affected limb is dry and sweat-free; the limb is stinging, burning, numb, feeling dull or lost, changing in a sock-like shape, feeling on the foot; Malnutrition, muscle atrophy, flexor and extensor muscles lose normal balance of traction tension, causing bones to sag and cause toe joints to bend, forming arch deformities such as arched feet, clubats, and claws. 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, poor skin dryness, hair loss, skin temperature drop, pigmentation, weakened or disappeared arterial pulse, vascular murmurs can be heard in stenosis. 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 ulcers can be classified into neurological ulcers, ischemic ulcers and mixed ulcers according to the nature of the lesion. 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.
3) Classification of diabetic foot: The classic classification method is Wagner classification method: 0: there is a foot with a risk of foot ulcer, 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.
In addition to routine physical examination, diabetic patients should pay special attention to the signs of the foot: such as the patient's walking gait, the presence or absence of foot deformities such as talc foot and toe valgus, muscle atrophy, paralysis; skin temperature, color And sweating, observe the skin has no blister, cracks and rupture; check the skin's feeling of temperature, pressure and vibration (tuning vibration); palpation of the dorsal artery with or without pulsation weakened or disappeared in the artery Vascular murmurs can be heard in the stenosis; careful examination of sputum reflections such as knee reflexes and tendon reflexes can be attenuated or disappeared.
1. Symptoms In the early stage of the disease, the patient often has itchy skin, cold limbs, slow feeling, edema, followed by continuous numbness of the double-legged sock. Most of them may have pain loss or disappear, and a few needle-like lesions and knives appear in the affected area. Cut, burning, pain, at night or when heated, the duck walks or walks against the stick. Some elderly patients have a history of severe limb ischemia, such as intermittent claudication and rest pain.
2. Signs of the patient's lower extremities and feet are dry, smooth, edematous, the hairs fall off, and the lower limbs and feet become smaller. The skin can be seen with scattered blisters, blemishes, ecchymoses, pigmentation, and cold extremities. When raising the lower limbs, the feet are white; when drooping, they are purple-red. Toenail deformation, thickening, brittleness, shedding, etc. Muscle atrophy, poor muscle tone. Common foot deformities, humeral head depression, metatarsophalangeal joint flexion, arched toe-like toe, toe overextension like claws. When the dorsal artery of the foot is occluded, the skin of the feet is bruising, the pulsation is very weak or disappears, and sometimes the vascular murmur can be heard at the stenosis of the blood vessel. The sensation of the extremities disappeared, the vibration of the tuning fork disappeared, and the Achilles tendon reflex was weak or disappeared.
When the foot is chronically ulcerated, a round penetrating ulcer forms on the ankle and the humeral head. Sometimes ligament tears, small fractures, bone destruction, and Charcot joints. When the dry gangrene is dry, the whole foot and the toes are dry and small, the skin is bright and thin, and it is light red. There are a number of black spots and dark spots in the edge of the toe. When wet gangrene, the feet are red, swollen, and the skin is ruptured, forming ulcers or abscesses of varying sizes and depths, and necrosis of skin, blood vessels, nerves, and bone tissue.
3. Clinically, according to the degree of diabetic foot lesions, it is divided into 6 levels, as shown in Table 1.
4. According to the local manifestations of diabetic foot lesions, it is often divided into three types: wet, dry and mixed gangrene. See Table 2, Figures 1-13.
(1) Wet gangrene: occurs mostly in younger diabetic patients. Due to the simultaneous obstruction of the arterial and venous blood flow and microcirculatory disorders, skin trauma, infection and disease. The lesions are mostly in the plantar area, the humeral head or the heel. The degree of disease varies from superficial ulcer to severe gangrene. Local skin congestion, swelling, and pain. Severe with systemic symptoms, elevated body temperature, loss of appetite, nausea, bloating, palpitations, oliguria and other bacteremia or toxemia.
(2) Dry gangrene: more common in elderly patients with diabetes. Atherosclerosis of the lower extremities, atherosclerosis of the extremities, stenosis of the lumen, thrombosis, occlusion. However, venous blood flow is not blocked. Partially manifested that the skin of the foot is pale and cool, and the toe area has black areas of different sizes and shapes, suggesting that the toe-end micro-arterial embolism and toe pain. Dry gangrene often occurs on the dorsal side of the toes and feet, sometimes the entire toe or foot becomes dark, dry, and small.
(3) Mixed gangrene: dry gangrene and wet gangrene are present in different parts of the same extremity. The scope of gangrene is large, involving most or all of the foot, and the condition is heavier.
1. Neuropathic diabetic foot manifests as local warmth, numbness, dryness, loss of pain, and arterial pulsation, which can lead to neuropathic ulcers (which occur mostly in the soles of the feet), Charcot's foot and neuropathic edema. The neuroischemic type showed a decrease in skin temperature, a decrease or even loss of arterial pulsation, rest pain, foot ulcer, and focal necrosis.
2. Both types of diabetes are prone to infection, ulcers often become the gateway to bacterial invasion, usually a variety of microbial infections, and quickly spread to surrounding tissues, eventually involving the whole body, tissue damage caused by infection is the main cause of amputation .
3. The key to diagnosing neuropathic and neuroischemic diabetic foot is the presence or absence of arterial pulsation. Therefore, the examination of arterial pulsations is very important, and this is the most easily overlooked. As long as the posterior tibial artery or the dorsal artery of the foot can be touched, the ischemia is not serious. If all disappears, it indicates a decrease in blood circulation. Measuring the pressure index ( systolic pressure / systolic pressure) is helpful in judging. In normal people, the ratio is usually >1, and in the case of ischemia, it is 1 to exclude ischemia. This has important reference value for clinical decision-making, because it means that macrovascular disease is not the main factor, so there is no need for angiography.
4. However, clinically, 5% to 10% of diabetic patients have elevated systolic blood pressure due to non-compressive peripheral vascular disease, which is still the case in the presence of ischemic lesions.
Therefore, the diagnosis of diabetic foot with an arterial pulsation that cannot be reached and a pressure index greater than 1 is difficult. Sometimes, especially in the case of foot edema, the examiner fails to touch the original arterial pulsation. At this time, the body should be re-examined after Doppler ultrasound localization. If it is still not accessible, it may be the middle layer of the vessel wall. It should be considered that ischemia exists. . In this case, the blood flow rate of the Doppler ultrasound, the examination of the waveform, and the measurement of the pressure of the big toe are helpful for diagnosis.
5. For distal obstructive lesions, the Doppler examination showed abnormal waveforms, and the normal rapid systolic pulsation and diastolic flow disappeared. As the lesion accelerated, the waveform changed from flat to disappear. References for the severity of arterial lesions can be found in the relevant books.
6. The measurement of the systolic pressure of the big toe requires a special thumb socket and a device capable of measuring the blood flow of the toe, such as laser Doppler or plethysmograph. The hallux pressure 30 mmHg indicates severe ischemia and poor prognosis. In addition, the percutaneous oxygen partial pressure of the foot is measured.
7. The degree of neuropathy needs to check whether the acupuncture and cotton sensation and the vibration sense (using a 128cps tuning fork) are normal, check whether there is a symmetric distribution of sore-like peripheral neuropathy, if the knee and ankle joints are missing Indicates the presence of peripheral neuropathy. The examination of autonomic neuropathy is difficult, and can be judged based on whether there is dry skin, chapped or sweating abnormality.
8. Once the neuropathy is diagnosed, it is important to determine whether the patient's protective pain perception is present. If it does not exist, it is more likely to suffer from diabetic foot ulcers. Two clinically valuable methods of examination are: vibration measurement and nylon fibril examination. The vibration feel can be measured using a manual vibration threshold meter. It should be noted that the vibration threshold increases with age and its measurements must be corrected using peer data. Nylon filaments can measure the pressure perception threshold. If a linear pressure equivalent to 10 g is not felt, it indicates that the protective pain sensation disappears.
Clinical diagnosis and grading of diabetic foot: Diabetic patients who have been examined for extremity lesions can be diagnosed as diabetic foot. According to the extent of the disease and with reference to foreign standards, the diabetic foot is divided into 0 to 5 grades.
Grade 0: There is no open lesion in the skin. Often manifested by insufficient blood supply to the extremities, cold skin, purple color, numbness, stinging, burning, feeling slow or loss, and high-risk performance such as toe or foot deformity.
Grade I: Open skin of the extremities. Superficial ulcers caused by blisters, blood blister corns or blemishes, frostbite or burns and other skin damage, but the lesions have not affected deep tissues.
Level II: Infected lesions have invaded deep muscle tissue. There are often cellulitis multiple pus and sinus formation, or infection along the muscle space to enlarge the foot and foot back ulcer, more purulent secretions, but there is no tissue damage in the tendon ligament.
Grade III: Destruction of tendon ligament tissue, cellulitis fusion forms a large abscess, purulent secretions and necrotic tissue increase, but bone destruction is not obvious.
Grade IV: Severe infection has caused bone defects, osteomyelitis and bone and joint destruction or formation of pseudoarthrosis. Some of the fingers or parts of the hands and feet have wet or dry severe gangrene.
Grade V: Most of the foot or the entire infection or ischemia of the foot, leading to severe wet or dry necrosis. The extremities become black and dry, and often spread to the calf joints and calves. Generally, surgical high amputations are taken.
