The quality of life for people with diabetes is often endangered. In addition to damage to the brain, kidney, visual analyzer and the nervous system, diabetic foot syndrome (SDS) plays a significant role. The main manifestations of pathology are considered to be the occurrence of chronic ulcers, critical ischemia, and pathologies of non-infectious bones and joints. Ulcers are considered the most threatening condition, since the addition of a secondary infection leads to the development of gangrene and loss of limbs.
Diabetic foot - a condition that endocrinologists deal with. Podiatry studies this issue in foreign countries, however, in our country this science is considered young, there are no narrow specialists.
The lower limbs are subject to significant stress throughout life. The entire weight of the body weight is transmitted to the structural elements of the feet. That is why damage to the blood vessels, nerve fibers and bone-articular apparatus on the background of diabetes mellitus provoke the development of the lesion and deformity of the foot.
Diabetic foot syndrome is considered an independent complication that occurs against the background of other chronic pathologies (retinopathy, nephropathy, angiopathy, neuropathy). The lower limb undergoes anatomical and physiological changes that manifest as purulent-necrotic processes.
In diabetes mellitus, there is absolute (1 type of disease) or relative (2 type of disease) pancreatic hormone insufficiency insulin. Such processes lead to high blood glucose and violations of all metabolic processes. The diabetic foot becomes the result of other late complications of the underlying disease: neuropathy, angiopathy, osteoarthropathy.
This condition causes the appearance of trophic ulcers in every second diabetic. Persistent high glucose levels cause damage to nerve structures (cells, fibers, receptors), which, in turn, causes impaired impulse transmission. In addition, nerve damage is also caused by angiopathies that occur in virtually every diabetic and lead to oxygen starvation of the nerve elements.
Nerve damage on the background of diabetes mellitus is one of the triggers in the development of diabetic foot
Violation of sensitivity causes atrophy of the muscular system of the foot. The deformation develops, which is accompanied by the following manifestations:
- keratinization of the skin in places of constant pressure;
- the appearance of natoptyshy;
- the formation of areas of necrosis of the skin;
- the occurrence of ulcers.
Another pathology against which a diabetic foot develops. This condition occurs infrequently (only 1% of diabetics) and is characterized by the pathology of bone structures. The second name for osteoarthropathy is Charcot's foot.
The main points that accompany the occurrence of osteoarthropathy:
- violation of innervation;
- microcirculation disorders with an increase in basal blood flow;
- reducing the number of young bone cells that are responsible for the formation of the matrix;
- deformation of individual bone elements;
- there are dislocations, subluxations and fractures.
Osteoarthopathy is a pathology accompanied by lesions of the bones of the foot.
Important! The process often affects the bones of the fingers, tarsus, less often - the ankle.
This is a lesion of blood vessels of various sizes, against the background of which diabetic foot syndrome develops. Vivid manifestations are atherosclerosis and occlusion, primarily occurring below the knee. Similar processes are considered to be significant in purulent-necrotic processes, which are manifested against the background of diabetic foot of the ischemic type.
There are a number of injuries that seem to be minor problems, but on the background of diabetes mellitus can cause more serious pathologies and become provoking factors for the development of diabetic foot.
This group includes ingrown nails, discoloration of the nail plates due to incorrectly chosen tight shoes, hemorrhage, or fungal lesions. Formation of calluses and corns. This also includes random mechanical damage to the integrity of the skin, heel cracks, deformation due to enlarged bones.
Separation is considered uniform and generally accepted. There are three main forms of the syndrome:
- An infected foot of the neuropathic type (60-65% of cases) - occurs on the background of long-lasting diabetes, combined with other complications. The skin is not changed, the pulsation on the arteries is preserved, all types of sensitivity are sharply disturbed, there is no pain.
- Gangrenous foot of the ischemic type (10-15% of cases) - patients complain of severe pain, the skin on the feet has a bluish tinge, cold to the touch. The pulsation is sharply reduced, but the sensitivity is at the same time sufficient. In general, patients in parallel suffer from high blood pressure, have significant indicators of cholesterol in the blood.
- Stop mixed type (20-25% of cases).
If the patient has ischemic pathology, the classification of the state of the occlusion of the lower extremities is used in the diagnosis:
- 1 - no symptoms (70% of cases).
- 2a - pain when walking more than 200 m;
- 2b - pain when walking less than 200 m;
- 3 - pain in complete rest;
- 4a - trophic pathology in combination with pain;
- 4b - painless trophic pathology.
Intermittent claudication - a symptom of lesions of the lower limbs, manifested in pain when walking
Classification of ulcerative lesions in diabetic foot syndrome:
- 0 degree - the integrity of the skin is not broken;
- Grade 1 - trophic ulcer, located superficially;
- Grade 2 - a trophic ulcer affecting the deep layers of the skin;
- Grade 3 - purulent inflammation of the bone structures or the formation of an abscess;
- 4 degree - gangrene, which has a clear delimitation;
- 5 degree - a common gangrene, in which an emergency amputation is performed.
The division into groups of the infectious process that has arisen in diabetic foot disease:
- Infectious process is absent - the wound or trophic ulcer does not have purulent discharge and signs of an inflammatory reaction.
- Mild infection - several symptoms of inflammation appear (swelling, redness, pain, local hyperthermia). Hyperemia captures the area of no more than 2 cm on all sides from the edge of the wound or ulcer.
- The infection is moderate - accompanied by lymphangitis, the formation of an abscess, gangrene. The process involves deep structural elements.
- Infection of severe degree - there are signs of severe intoxication of the body, lower blood pressure, increased heart rate, high blood sugar levels, azotemia.
Symptoms of pathology
Any type of complication may be accompanied by purulent-necrotic lesions. The symptoms of a diabetic foot are based on whether the disease is accompanied by an acute surgical pathology that requires urgent surgical assistance or not. In its absence, the type of diabetic foot can be differentiated on the basis of complaints from patients.
The first signs of a neuropathic type are manifested by aching pains arising in the area of the feet, legs and thighs. Pain syndrome decreases after movement, changes in the position of the lower limb. Patients complain of decreased sensitivity, tingling, discomfort, burning, feeling as if crawling creeps. Frequent manifestation is increased swelling, weakness of the muscular system.
A bright manifestation of pain - a sign of a neuropathic diabetic foot
Symptoms of ischemic type of foot appear as follows:
- severe pain in the legs when walking;
- patients are forced to make stops, so that pain syndrome is reduced;
- pain that occurs when the patient is in a horizontal position and disappears after the patient sits down;
- cramps, especially at night;
- feeling cold in the toes.
Visual inspection of patients
The table shows the main points that allow to differentiate the types of diabetic foot.
The skin is pale bluish, cold to the touch, visible cracks
The color and temperature of the skin is not changed, there are areas of thickening of the epidermis, which have the ability to exfoliate.
No deformation of the legs
Severe limb deformity, significant swelling
Arterial pulsation sharply reduced or completely absent
Arterial pulsation in good condition
Visually visible necrotic areas, trophic ulcers are highly sensitive, painful
Trophic ulcers are not accompanied by pain
Important! With photos and pictures of visual manifestations of pathology can be found on the website or on the pages of specialized literature.
Timely determination of the syndrome will slow down the progression of the condition, selecting the right treatment, and prevent the need for amputation of the lower limb. First of all, the specialist collects data on the underlying disease and clarifies the presence of complaints. Next, an inspection of the lower extremities is carried out: the plantar and dorsal surface, the gaps between the fingers.
The specialist specifies the color of the skin, its temperature, the presence of hair. Evaluates skin turgor and elasticity, pulsation of the arteries, the presence of swelling and trophic defects. If the doctor can not listen to the pulse in the peripheral arteries, dopplerography is performed with a portable device.
Portable dopplerograph - a device that allows you to listen to the presence of a pulse on the peripheral arteries
With the help of a neurologist, the state of sensitivity is assessed:
- tactile - monofilament;
- pain - hammer with a needle at the end;
- vibration - tuning fork;
- temperature - cold and warm objects.
To clarify the state of the internal elements and the osteo-articular apparatus allows radiography. For better visualization, use two projections of shooting.
Specific ways to determine the presence of pathology:
- Test Alekseev. Estimates the change in temperature of the lower limbs after walking. In patients with circulatory pathology, the indices decrease by 1-2 ° C after 400 m.
- Sample Marburg. Against the pallor of the plantar surface of the foot, blue spots are clearly visible.
- Sample Ratshaw. The patient lies on a hard surface, lifts both legs and crosses them. Within a few minutes, the pallor of the feet appears.
- Sample Cossacks. On the front surface along the entire leg is carried out with a blunt object. Blood supply failure proves a sharp break of hyperemia on the skin.
When confirming diabetic foot syndrome, the patient is hospitalized in an endocrinological hospital for correction of the condition and prescription of therapy. Mandatory research methods at this stage are:
- examination and palpation of the legs, clarification of sensitivity;
- in the presence of trophic ulcers - baccap contents with antibiogram;
- duplex scanning of arteries - ultrasound, which allows to clarify the state of the vessels and blood circulation through them;
- arteriography of the lower extremities - radiopaque method, which is carried out by introducing a contrast agent and conducting further x-ray images;
- oximetry - clarification of the presence of ischemia, its degree;
- X-ray, CT, MRI - examination of the state of the internal structures of the foot;
- laboratory tests (general tests, blood sugar, biochemistry, coagulogram);
- examination of a neurologist, nephrologist, oculist.
Blood test for glucose is a mandatory diagnostic method, allowing to establish the degree of compensation of diabetes
Features of treatment
The problem of treating the complications of diabetes is not fully resolved. As before, half of all patients who undergo amputations of the lower extremities are diabetics. Treat pathology begin with its causes - hyperglycemia. It is very important to achieve compensation for diabetes, maintaining glucose levels up to 6 mmol / l, and glycated hemoglobin - up to 6.5%.
The treatment program includes unloading of the diseased limb, which is considered mandatory for any type of complication, especially after surgery. Such activities are aimed at reducing inflammation, swelling, preventing the trauma of the ulcer itself. The fastest healing takes place. Ulcers that have not healed for several months or even years, epithelialize for 6 weeks.
Bed rest and crutches are not effective in this case. The alternative is therapeutic shoes, which can be made from medical materials or at home (for example, from old sneakers). The peculiarity of such shoes is that the tips of the fingers or the heel remain open.
Medications used in the treatment of the syndrome:
- drugs that improve blood flow;
- drugs that reduce cholesterol levels in the blood;
- medications that affect the state of vascular wall tone.
Treatment of trophic ulcers
First of all, the natoptysh, which formed at the edges of the ulcer, is removed. It is excised with a scalpel and scissors. If necessary, open up abscesses, as much as possible clean the necrotic zones.
Local treatment follows the rule: "wet defects need moisturizing dressings, and dry ones need dry ones." The center of the ulcer with exudate is treated with Dioxidine, hypertonic solution, Miramistin, Chlorhexidine. The frequency of processing is chosen individually (usually 2 times a day). Allow to smear defects with iodine-containing solution Povidone-iodine, outside - with anti-inflammatory creams and ointments (Ibuprofen, Hydrocortisone).
Preparations for the treatment of "wet" ulcers
Important! 5% iodine solution, brilliant green, a solution of potassium permanganate are not used for the treatment of ulcers.
Trophic ulcers and necrosis with signs of infection are treated with antibacterial drugs. The choice of means is carried out after bakposev and clarify the sensitivity of microorganisms to antibiotics.
More information about the treatment of diabetic foot can be found in this article.
The intervention of surgery for diabetic foot syndrome has the following indications:
- an infectious process that threatens the patient’s life;
- bone inflammation, osteoarthritis;
- deep ulcerative defect;
- significant defects after previous operations;
- critical ischemia, if there are no contraindications.
In such conditions, amputation is required. The height is determined by the operating physician depending on the level of viable tissues and the criticality of the condition.Correction of arterial insufficiency is carried out with the help of angiosurgical interventions: balloon angioplasty, stent placement, bypass surgery, endarterectomy.
Innovation in treatment
Cuban doctors have proposed an innovative method of therapy, which is aimed at preventing the progression of pathology, reducing the risk of gangrene, accelerating tissue regeneration processes and healing defects. The Cuban drug Eberprot-P is a recombinant human epidermal growth factor for healthy cells. The treatment regimen is selected individually in each clinical case. Unfortunately, to purchase this tool in the public domain is currently problematic.
Eberprot-P - an injection tool used in the treatment of diabetic foot
The use of medicinal plants is one of the subsidiary methods of treating the syndrome. Efficiency showed the use of leaves and blueberries. It is necessary to introduce berries into the daily ration (up to 3 cups per day), and fragrant healing tea is brewed from the leaves.
Another remedy is burdock leaves. Compresses are made of them, having previously treated the foot with Furacilin solution and smeared with a small amount of honey. From above fix the leaves of the plant. Repeat the procedure in the morning and evening.
Washing the skin defects is carried out with a decoction of the dry fruits of the bird cherry. A tablespoon of raw materials is poured with a glass of boiling water, brought to a boil and boiled over low heat for 15 minutes and filtered. The solution is ready to use.
More information about the treatment of diabetic foot at home can be found in this article.
Diabetic foot care
A prerequisite is daily washing of the feet with soap and warm water. Then you must thoroughly dry the skin, but do not rub them. Foot care includes self-examinations to determine dry skin, damage, blistering, scratching, corns, ingrown nails.
The skin is checked for redness, pain in certain areas, and an increase in local temperature. If an ulcer or callus was found, it is forbidden to open them yourself. You should seal the place with a plaster, change your shoes and report the problem to the doctor.
Choosing the right footwear is a preventative measure in the development of complications.
The following rules will reduce the risk of complications:
- cut nails need after bathing (they become softer);
- Do not cut the corners of the nail plate;
- walks should take place in comfortable shoes with the right size so that it is not tight and does not rub calluses);
- do not walk barefoot;
- give up shoes with heels;
- socks should be made of natural fabrics;
- if necessary, use orthopedic shoes;
- when bathing, check the temperature with your hands, not with your feet (sensitivity can be sharply reduced);
- don't cross your legs.
Compliance with expert advice, support for optimal glycemia and daily foot care are factors that can reduce the risk of developing diabetic foot, and when it occurs, slow down progression.