Understanding Diabetic Foot: A Comprehensive Guide For General Practitioners

Contents
Foreword
Preface
About the Editor
List of Contributors
Section 1 Introduction to Diabetes
Chapter 1 Diabetes in the World
Introduction
Diabetes Hot Spots in the World
India
China
South East Asia
Singapore
References
Chapter 2 Diabetes in Singapore Today
Introduction
Changing Dynamics
Facts and Figures (Figure 1 — Straits Times, 14 April 2016)
Parliamentary Debate on Diabetes, 13 April 2016
War on Diabetes, April 2016
National Day Rally Speech, 2017
References
Chapter 3 Prevention of Diabetic Foot: Role of Government Intervention
Diabetic Foot Strategy
Prevention is Key
Patient Education
Curriculum for Patient Education
Annual Foot Screening
Role of Government Involvement
Conducting National Public Awareness Programme
National Programme for Public Awareness
Algorithm for Prevention of Diabetic Foot
Summary
References
Chapter 4 Understanding Diabetes
How Insulin Works?
Normal Individuals
Diabetic Individuals
Risk Factors
Symptoms
Glossary
Chapter 5 Complications of Diabetes
Acute Complications
Acidic Blood — Diabetic Ketoacidosis (DKA)
“Thick” Blood — Hyperglycemic Hyperosmolar State (HHS)
Low Blood Glucose — Hypoglycaemia
Chronic Complications
Heart Attack — Coronary Artery Disease
Stroke
Leg Pain — Peripheral Arterial Disease (PAD)
Kidney Damage — Diabetic Nephropathy
Eye Problems — Diabetic Retinopathy
Nerve Damage — Diabetic Neuropathy
Diabetic Foot Complications
Glossary
Section 2 Introduction to Diabetic Foot
Chapter 6 Types of Diabetic Foot Complications
Introduction
Pathophysiology
Neuropathy
Vasculopathy
Immunopathy
Types of Diabetic Foot Problems
Skin Infection — Cellulitis
Abscess
Necrotising Fasciitis
Bone Infection — Osteomyelitis
Joint Infection — Septic Arthritis
Dead Tissue — Gangrene
Joint Breakdown — Charcot Joint Disease
Ulcers — Wounds
Infective Wound
Ischaemic Wound
Both Infective and Ischaemic
Neuropathic Wounds
Pressure Wounds
Classifying the Diabetic Foot Wound
References
Chapter 7 Know Your Foot: A simple Guide to Anatomy and Biomechanics of the Foot
Introduction
The Anatomy
Bones of the Leg
Bones of the Foot
Muscles of the Lower Leg
Muscles of the Foot
Blood Vessels of the Leg and Foot
Nerves of the Foot
How We Walk — The Gait Cycle
Glossary
Section 3 Assessing Diabetic Foot
Chapter 8 Examining Diabetic Foot in Your Clinic
Introduction
History Taking
Patient Profile
What is the Patient’s Profile?
What is the Patient’s Socioeconomic Status?
Symptoms
Where is the Pain?
Is There Vascular Claudication?
Is There Rest Pain?
Is There swelling?
Is There Deformity?
Is There an Ulcer?
Site of Ulcer
Contents of Ulcer
Is There Gangrene?
Is There Numbness?
How Severe is the Numbness?
Has the Patient had Recent Trauma?
Has the Patient Sustained Self-inflicted Trauma?
Does the Patient Self-medicate?
What is the Type of Footwear Worn?
Medical History
What is the Type of Diabetes Mellitus Present?
What is the Type of Diabetic Medication Used?
Does the Patient Monitor His Diabetes?
Does the Patient Know His HbA1C Level?
What are the Symptoms of Poorly Controlled Diabetes?
What are the Complications of Diabetes Present?
What are the Co-morbidities Present?
Are Risk Factors of Diabetes Present?
Social History
What is the Functional Status of the Patient?
What is the Patient’s Occupation?
Is There a Family History of Diabetes?
Is There a Caregiver?
Performing the Clinical Examination
Position of Patient
Perform Step-by-Step Examination
General Examination
Vital Signs
Examine Cardiovascular System
Examine Respiratory system
Examine Abdomen
Local Examination
Examining an Ulcer
Assessing Diabetic Foot Triad
Assessing Vasculopathy
Femoral Pulse
Popliteal Pulse
Dorsalis Pedis Artery (Figure 12)
Posterior Tibial Artery (Figure 14)
Assessment for Sensory Neuropathy
Pinprick Test
Position Sense
Vibration Sense
Ten-Points Semmes Weinstein Monofilament Test (SWMT) (Optional)
Assessment for Immunopathy
Probe Test
References
Chapter 9 Investigating Diabetic Foot in Your Clinic
Introduction
Blood Tests
Markers of Infection
Markers of Healing
Markers of Infection
Culture and Sensitivity (c/s) Studies
Radiological Tests
Chapter 10 Recognising Osteomyelitis in Diabetic Foot
Introduction
Location
Clinical Examination
Probe-to-bone Test
OM in a Non-healing Ulcer
Investigations
Blood Investigations
Plain Radiographs
High Index of Suspicion
References
Section 4 Treating Diabetic Foot
Chapter 11 Treating Diabetic Foot: A Holistic Approach
Introduction
Holistic Treatment
Endocrine Control
Nutrition
Wound Bed Preparation
Time Concept
Types of Dressings
Negative Pressure Wound Therapy and Negative Pressure Wound Therapy with Instillation
Antibiotics
References
Chapter 12 Antibiotics for Diabetic Foot Infections: A Practical Guide for the General Practitione
Introduction
Diagnosis
Skin and Soft Tissue Infections
Osteomyelitis
Local Microbiological Data
Collection of Specimen for Culture
Collecting a Wound Swab
Severity of Infection
Outpatient Management of Diabetic Foot Infections
Choosing the Antibiotic Regimen
Duration of Antibiotics
Indications for Hospitalisation
References
Section 5 Dressing Diabetic Foot Wounds
Chapter 13 Choosing the Appropriate Wound Dressing: A Practical Guide
Introduction
Basic Science of Wound Healing
Inflammatory Phase
Proliferative Phase
Maturation Phase
Take Home Message
Functions of a Dressing
Characteristics of An Ideal Dressing
Types of Wound Dressings
Summary
Chapter 14 Dressing A Wound: A Step-by-Step Guide for the General Practitioner
Introduction
Components of a Wound Dressing
Cleansing Solution
Wound Product
Disposable Dressing Set
Procedure
Section 6 Managing Patients with Diabetic Foot Wounds
Chapter 15 Getting to Know the Operation Performed on Your Patient
Introduction
Surgical Debridement
Split Skin Grafting
Minor Amputations
Classification on Amputations
Ray Amputation
Trans-Metatarsal Amputation
Mid-foot Amputations
Pirogoff Amputation
Why Distal Amputation Preferred
Major Amputations
Below-knee Amputation
Above-knee Amputation
References
Chapter 16 When to Refer Diabetic Foot Complications?
Introduction
Performing Diabetic Foot Screening
What is Diabetic Foot Screening?
History
Examination
Referring Abnormal Findings of Diabetic Foot Screening
Patient Education
Referring Diabetic Foot Complications that Present to Your Clinic
References
Section 7 Educating Patients with Diabetic Foot Wounds
Chapter 17 Living with Diabetes
What is Diabetes?
Causes
Symptoms
Complications
Diagnosis
Treatment: Medication
Insulin Injections — Type 1 Diabetes
Oral Tablets — Type 2 Diabetes
Monitoring
Hypocount Self-monitoring
HbA1c Test
Eye Examination
Foot Screening
Healthy Lifestyle
Diet
General guidelines on diet
Weight
Exercise
What types of exercises are suitable?
No Smoking
Tips to help you stop smoking
No Alcohol
Chapter 18 Taking Care of the Foot
Introduction
Step 1: Foot Hygiene
Step 2: Skin Care
Step 3: Nail Care
Step 4: Inspecting Your Feet
Step 5: First Aid for Foot
Managing Abrasions or Minor Cuts
Managing Insect Bites and Stings
Managing Bleeding
Managing Burns and Scald
Common Misconceptions
Summary Tips and Checklist
Checklist for Daily Inspection
When Travelling
Flying to Your Destination
Upon Arrival
In Subtropical or Tropical Countries
Foot Screening
Frequency and Duration
Where
What to Expect: The Procedure
What to Bring + Wear
Chapter 19 Choosing Your Footwear
Introduction
What Makes a Good Shoe?
Avoid These!
Choosing Your Shoes — Do’s and Don’ts
Before Wearing Shoes
Fact or Fiction?
Test Yourself!
Checklist
Chapter 20 Education Pamphlets
1. Knowing Diabetes
2. Happy Feet
3. A Patient’s Guide to Footwear
Section 8 Supplement for Nurses & Podiatrists
Chapter 21 Team Approach for Diabetic Foot
Introduction
A Multidisciplinary Team
Members
Function of a Multidisciplinary Team
Weekly Team Round
Multidisciplinary Teaching Sessions
Clinical Pathway
Surgery
Outpatient Clinics
Patient Education
Outcome of a Multidisciplinary Team Approach (Figure 2)
Amputation Rates
Complication Rates
Costs
References
Chapter 22 Managing Diabetic Foot Ulcers — A Nursing Perspective
Introduction
Identification of the At-Risk Foot
History
Holistic Assessment
Skin Conditions
Hygiene
Nursing Consideration for Hygiene
Deformity
Nursing Consideration for Deformity
Footwear and Device
Nursing Consideration for Footwear and Device
Qualities of a Good Dressing Protocol
Patient Education on Foot Care
Conclusion
References
Chapter 23 Nutrition and Diabetes
The Role of Nutrition and Wound Healing
Macronutrients
Fluids
Fat
Carbohydrates
Protein
Micronutrients
Vitamin A
Vitamin C
Vitamin D
Other Micronutrients
Zinc
Iron
Trace Elements
Summary
References
Chapter 24 Dressings and Alternative Therapies
Introduction
Wound Bed Preparation
Medical Management
Endocrine Control
Medical Nutrition Therapy
Dressing of Diabetic Foot Ulcers
Types of Wound Dressings
How to Choose an Appropriate Dressing
Adjunctive Therapies
References
Chapter 25 Negative Pressure Wound Therapy
Basic Science
Application of VAC Dressing
Case Study
Case Study 2
Innovative Techniques and NPWTi
White Foam
Veraflo Therapy (NPWTi)
References
Chapter 26 Maggot Debridement Therapy
Introduction
Basic Science
Case Study 1
Case Study 2
References
Chapter 27 Offloading Diabetic Foot
Introduction
Offloading Devices
Specialised Footwear
Ready-Made Diabetic Shoe
Offloading Insoles
Forefoot Wedge Offloading Shoe
Heel Wedge Offloading Shoe
Charcot Joint Disease (CJD) and Offloading
Offloading Walking Devices
Custom-made Footwear
References
Chapter 28 Footwear and Offloading for Diabetic Foot Persons
Introduction
Definition of Footwear
Facts About Load on Foot
DM Foot Cycle and Roles of Offloading Footwear
2019 IWGDF Guideline for Prevention and Offloading Footwear
Offloading Modalities
Total Contact Cast
Ankle Foot Orthosis (AFO)
Common Foot Orthosis for Diabetic Foot Patients
Common Shoe Modification for Diabetic Foot Patients
Custom Moulded Shoes
Shoes for Diabetic Foot Patients
Characteristics of Proper Shoes
Characteristics of Improper Shoes
Proper Shoes Fit
10 Tips to a Great Shoe Fit
Socks
Risk Category and Recommending Footwear
Conclusion
References
Chapter 29 A Quick Look into Hyperbaric Oxygen Therapy
Introduction
Hyperbaric Oxygen Therapy
Effects of HBOT on Wound Healing
Case Study
Normobaric Oxygen Challenge Test
HBOT and Necrotising Fasciitis
HBOT and Microangiopathy
HBOT or no HBOT? — The Continuing Controversy
References
Chapter 30 Charcot Joint Disease
Introduction
Historical Background
Epidemiology and Etiology
Pathogenesis
Neurotraumatic Theory
Neurovascular Theory
Modern Theory
Medical History
Clinical Phases of CJD
Acute Phase
Bone Destruction/Deformity Phase
Stabilisation Phase
Radiological Presentation
Atrophic
Hypertrophic
Eichenholtz Classification System
Stage 0: At Risk Stage — The “Charcot in Situ” Stage
Stage 1: Developmental Stage — Acute Stage
Stage 2: Coalescent (Quiescent) Stage
Stage 3: Remodeling Stage
Brodsky’s System of Classification
Type 1: Tarsometatarsal (Lisfranc’s) joints
Type 2: Hindfoot
Type 3
Type 4: Multiple Regions
Type 5: Forefoot
Clinical Examination
Investigations
Hematological and Biochemical Studies
Tissue Biopsy
Radiographs
Conservative Treatment of CJD
Acute Phase
Offloading with Total Contact Cast
Offloading with Walking Devices
Custom-made Footwear
Adjunctive Therapy
Operative Treatment of CJD
Outcome of Treatment
References
Chapter 31 Necrotising Fasciitis
Introduction
Types of Necrotising Fasciitis
History
Profile of Patients
Predisposing Factors
Comorbidities
History
Pathophysiology
Examination
Clinical Findings
Investigations
Microbiological Tests
Radiological Tests
Bedside Finger Test
Treatment
Antibiotics
Combination Therapy
NUH Antibiotics Guidelines
Medical Treatment
Surgery
Complications
Mortality
References
Chapter 32 Rehabilitating the Below-knee Amputee
Introduction
Pain Control
Wound Care and Oedema Control
Contracture Prevention and Joint Range of Motion
Physical Conditioning
Psychological Support and Education
NUH Below-knee Rehabilitation Programme
Criteria for Discharge
Plan for Discharge
Follow-Up Clinic Appointments
Stump Preparation for Prosthesis Fitting
Cost of Prosthesis
References
Appendix A NUH Diabetic Foot Team
Need for Diabetic Foot Service
Research Teams for Diabetic Foot
First Research Team, 2005
Second Research Team, 2006
Third Research Team, 2007
Fourth Research Team, 2008
Fifth Research Team, 2009
Sixth Research Team, 2010
Seventh Research Team, 2011
Eighth Research Team, 2012
Ninth Research Team, 2013
Tenth Research Team, 2014
Eleventh Research Team, 2015
Twelfth Research Team, 2015
Publications by NUH Diabetic Foot Team
Books
Book Chapter
Publications in Journals
Courses On Foot Screening
First Training Course for Diabetic Foot Screening (2006)
Second Regional Training Course for Diabetic Foot Screening (2007)
Third Regional Training Course for Diabetic Foot Screening (2008)
Fourth Regional Training Course for Diabetic Foot Screening (2010)
Fifth Regional Training Course for Diabetic Foot Screening (2011)
Conclusion
Appendix B History of Asia Pacific Association for Diabetic Limb Problems
Introduction
Third APCDLP
Fourth APCDLP
Fifth APCDLP
Sixth APCDLP
Seventh APCDLP
Eighth APCDLP
Ninth APCDLP
10th APCDLP
11th APCDLP
12th APCDLP
13th APCDLP
14th APCDLP
15th APCDLP
16th APCDLP
17th APCDLP
Next Three Conferences
Office Bearers of APADLP from 2000 to 2002
Past Presidents of APADLP