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Type I
- Insulin-dependent diabetes mellitus (IDDM)
- May be genetic (IA) or idiopathic (IB)
- Do not produce insulin
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Type II
- Overweight (80%)
- Diagnosed later
- Insulin resistance; exact cause unknown
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Hyperglycemia
- RBCs become adhesive and less able to release oxygen
- Platelets become adhesive and stick to endothelial walls
- Accumulation of sorbitol may cause tissue damage
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The Neuropathic Foot- Etiology of Foot Ulceration
- Cause is multifactorial
- Peripheral neuropathy is a main cause
- -----Sensory loss
- ----Increased mechanical stress
- Risk of PVD is greater in diabetes
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Sensory Component
- subjective: numbness, paresthesias, cold feet, and pain
- objective: absence of protective sensation* and impaired vibratory sensation*
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Motor Component
- Weakness of intrinsics first
- Atrophy predisposes patient to ulceration
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Autonomic Component
- decrease vasomotor regulation
- decrease tissue hydration
- increase rate of callus formation
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Other Factors: Mechanical Stress
- Pressure
- -----Deformity or ¯ ROM ® high plantar pressures (heel and metatarsal heads)
- Shear
- ----intrinsic foot stress (e.g. bony prominences)
- ----extrinsic foot stress (e.g. footwear)
- Repetitive stress is the most common form of injury
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Diabetic wound Other Factors
- Dry skin susceptible to injury
- Callus causes increased pressure
- Obesity
- Visual loss
- Joint limitation
- Foot deformities
- Previous ulcer or amputation
- Improper footwear
- Impaired immune response
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Charcot Arthropathy
- Neuropathic fracture and dislocation
- Multiple causes: wear and tear, minor repetitive trauma, neuropathy, ¯ blood flow
- Clinical signs: acute swelling, heat, erythema, subacute decrease in symptoms with deformity after fracture healing
- Treatment: NWB/cast ® PWB with device ® CROW
- Arthropathy leads to high pressure in certain areas of the foot predisposing these areas to ulceration
- Will but a sharko restraint orthotic walker
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Characteristics of Diabetic Wounds
- Round, punched out lesions
- Plantar location
- ----Metatarsal heads
- ----Heel
- ----Great toe (with hallux rigidus)
- ----Midfoot (with rocker bottom deformity)
- Dorsal toes with claw-toe deformity
- Isolated callus rim
- Minimal drainage
- Lack of pain
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Classification of Neuropathic Ulcers Wagner System
- 0 No open lesion; deformity or cellulitis
- 1 Superficial ulcer
- 2 Deep ulcer to tendon, bone, capsule
- 3 Deep ulcer w/ abscess, osteo, or joint infxn
- 4 Localized gangrene
- 5 Gangrene of entire foot
- Grades 4 and 5 require some level of amputation.
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UTHSCSA Diabetic Wound Classification System
- Depth 0-3
- -----0 = pre or post ulcer with epithelialization
- ----1 = superficial; not involving tendon or bone
- ----2 = penetrates to tendon or capsule
- ----3 = penetrates to bone or joint
- Infection / Ischemia A-D
- ----A = non-infected, non-ischemic
- ----B = infection
- ----C = ischemia
- ----D = infection plus ischemia
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Neuropathic Foot Examination
- Circulation: Capillary refill, ABI, pulses
- Sensory testing
- Skin inspection/temp
- ROM exam: Ankle motions, big toe motions ( see if WNL)
- Intrinsic and extrinsic muscle strength testing
- Evaluation of footwear
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