The Diabetic foot depends on two etiopathogenetic moments:
- Diabetic neuropathy, ie the suffering of peripheral nerves because the
alteration of glucose metabolism is responsible for this event. In this case we
speak of neuropathic foot (see diabetes);
- Chronic obstructive arterial disease, ie the lesions and stenoses of the
peripheral arteries, responsible for poor blood supply and, therefore, of
ischemic suffering of the limb and of the foot in particular. In this case we
speak of ischemic foot. If the two etiopathogenetic moments persist, we will
have the neuroischemical foot.
-Sometimes it's more simply the decubitus injury of the foot, for example of the
wounds infected at the calcaneal level
Foot of Charcot, diabetic foot, with ulcerations
and deformations, hyperaratosis of plantar,
cavity etc.
The foot performs very complex functions: it is not only an organ in charge of
the movement, but has its own sensitivity and peripheral perception (for example
of the heat, the roughness of the ground, etc.) and informs the brain about the
subject's posture and receives engine orders. Being a region of the body far
from the heart pump, the supply of blood and oxygen happens more difficult but
the conservation of trophism of the foot occurs through the fine regulation of
the bloodstream, the work of nerve fibers that work independently, ie regardless
of consciousness.
Diabetic neuropathy affects:
- the sensitive nerves (sensory neuropathy), for example, the subject can wear
a tight shoe without annoying, with serious damage to the foot! Sensitivity is
evaluated with an instrument: the monofilament of Semmes-Weinstein or the
diapason.
- the motor nerves (motor neuropathy), causing hypotrophy of the muscles of the
foot that in this way yield under the load, up to pictures of muscular atrophy
and bone and joint deformation, because the muscle retracts with the tendon and
pulls the joint back with self (phenomenon of cavity of the foot, of the algas
of the big toe, etc., of hyperkeratosis ("calluses") because the foot rests
badly, more in some areas.
- vegetative nerves (autonomic neuropathy), responsible for trophic skin
problems, with dryness of the skin, anhidrosis, microcirculation disorders and
ulcerated lesions, which can then become infected. The neuropathic foot
therefore loses its functions and changes the muscular balance, the perception
of the stimuli, the vegetative autoregulation, with severe degeneration of the
tissues.
The first problem, therefore, to be addressed is the prevention of trophic
lesions of the diabetic foot, immediately correcting the altered posture of the
foot to combat hypercharging and the consequent plantar ulcers, which are always
due to neuropathy reasons. But since ulcers are formed in any case, the problem
is to treat the ulcer as soon as possible and adequately.
The treatment of neuropathic plantar ulcers is basically based on three moments:
- local treatment of the lesion (ie the cleaning of the ulcer, removing the
necrotic material (debridement), the "callus" and implementing a good dressing
table and dressing)
- treatment of any infections (for example by carrying out a sampling with swab
and culture.
- the discharge of the ulcerative lesion (that is to avoid that it is burdened
by the weight of the body during walking, which is implemented with appropriate
insoles dug at the plantar ulcer, which must be prescribed ad hoc or, in the
worst cases, with rest bed and with the use of a wheelchair, often impractical.
Foot of Charcot, diabetic foot, ulcerations and
bilateral deformations, hyperaratosis of plantar,
cavity
The histological features of peripheral obstructive arterial disease (AOCP) in diabetics do not differ substantially from the non-diabetic population arteriopathy. It is sometimes characterized by pain in walking, the so-called "claudication", see link on this site. These are lesions of the artery wall starting as lipid plaques, proceeding with fibrous tissue and calcium deposition, until stenosis stenosis, that is when the vessel is almost closed and the pressure at the ankle measured with Winsor index is <a 50 -70 mmHg and to the toe 30-50 mmHg (TASC criteria, TransAtlantic Inter-Society Consensus). The AOCP affects both legs and mainly affects the arteries below the knee. The latter is the most important characteristic for the treatment: the arteries of the leg and foot are of smaller caliber than the arteries of the thigh, so it is more difficult to intervene therapeutically on them.
It is always accompanied by the presence of diabetic neuropathy. It consists of
a bone pathology and the joints of the foot, which deform and fragment, until
the loss of the foot's architecture, with a severe deformity of the foot. This
condition, if not diagnosed and therefore not cured at its onset (so-called
acute Charcot), evolves towards pictures of deformities such as to obtain ulcers
that are difficult to heal or recurring and which may eventually lead to limb
amputation. In acute Charcot, the onset is characterized by signs of acute
inflammation, with redness, pain and increased temperature of the foot; it is
also possible that there are small fractures that can also escape radiographic
examination. The acute phase therapy of the Charcot consists in immobilization
with a rigid boot (different from the discharge device for the treatment of
neuropathic ulcers); it is absolutely categorical in this phase that the foot
does not rest on the ground because the load contributes to the progress of bone
subversion, with therapy with diphosphonates. Once the stabilization of the
framework has been achieved, it will be necessary to categorically prescribe an
orthosis with a tailored shoe and footbed on the cast that perfectly contains
the foot and ankle, providing as much as possible to stabilize it during the
pass.
If the acute phase is not diagnosed and treated correctly and you continue to
walk with common shoes, progressively the relationships between the various
bones of the foot are altered, the normal articular relationships are lost,
fragmentations and parcellar detachments are lost and you start the picture of
chronic Charcot.
Foot of Charcot, diabetic foot, ulcerations and bilateral deformations,
hyperaratosis of plantar, cavity
A frequent and dangerous complication of an ulcer is infection.
An infected ulcer can cause:
- systemic phenomena that can jeopardize not only the limb salvage but the
patient's own life (septic status, septicemia)
Infections can cause abscesses, ie pockets of pus that drain; the anaerobic
infections that cause a full-thickness necrosis of the soft tissues. Gangrene is
the best known clinical picture in diabetics. Gangrene (ie full-thickness
necrosis of the soft tissues) can involve small parts (phalanges), larger parts
(toes) up to most of the foot (forefoot, meso and back-rest). It can be dry, and
this represents a relative or humid or gaseous urgency requires an absolute
urgency because in this case we risk not only the loss of the limb but the
patient's life (sepsis). Or it can be gaseous, that is, necrosis or mixed germs
that give cellulite or necrotizing fasciitis, infections that often extend to
the bone causing osteomyelitis with the result of amputations of the toes, the
foot, the leg and the thigh, depending on the headquarters and the gravity of
the framework. In necrotizing fasciitis the infection can extend in a
devastating way in a few hours through the band covering the muscles (in general
the latter are not involved); the fascia usually appears gray, necrotic and the
subcutaneous necrotic, low-cut tissue. Acting quickly means removing what is
infected is present: the surgical treatment allows us to drain (ie evacuate) the
pus and allows us intraoperatively to evaluate how deep and extensive the
infection is and how the tissues are involved (tendons, muscles, bones) ).
Basic rules for the prevention of foot injuries
- Inspect and wash your feet every day
-Check the water temperature with the elbow or with the thermometer (due to neuropathy, see above!)
- Dry well but gently, possibly with hair dryer
- Use socks that do not tighten and change them every day
- Remove the foot if dry with specific creams
-Do not use callipers or sharp tools for calluses
-Cut the nails with scissors with rounded ends, round with cardboard file
-Do not walk barefoot
-Do not use direct heat sources (hot water bags, radiators, fireplaces, etc.)
-Use comfortable shoes with a round toe and heel not more than 4 cm
When fitting new shoes, check the foot after a few minutes of walking