Makindo Medical Notes

About

• 👣 Amputations are common but preventable with early recognition and intervention.
• 🩺 The old belief that microvascular disease made surgery futile is outdated — active management is highly beneficial.
• 🤝 A multidisciplinary approach (surgeons, endocrinologists, radiologists, microbiologists, podiatrists) is key for optimal outcomes.

Etiology (Multifactorial)

• 🩸 Vascular injury: Accelerated atherosclerosis → ischaemia.
• 🍬 Tissue hyperglycemia: Favors infection.
• ⚡ Autonomic neuropathy: ↓ sweating → dry skin → fissures.
• 🦶 Sensory neuropathy: Loss of protective sensation → unnoticed trauma.
• 🦴 Motor neuropathy: Deformities (e.g., claw toes) → high pressure points → ulcers.

Clinical Presentation

• Signs of ischaemia: 🔵 cold limb, weak or absent pulses.
• Ulceration or necrosis, often on pressure points.
• Neuropathic deformities (e.g., claw foot, Charcot changes).

Investigations

• Bloods: 🧪 FBC, U&E, LFTs, clotting, HbA1c, CK.
• Imaging:
  • 📈 ECG (look for AF / recent MI).
  • 🫁 CXR (cardiomegaly, heart failure).
  • 🩻 Doppler (peripheral flow), MRI (osteomyelitis), MR angiography (surgical planning).

Wagner Classification for Diabetic Foot Ulcers

• 0️⃣ Intact skin
• 1️⃣ Superficial ulcer
• 2️⃣ Ulcer → tendon, bone, or joint capsule
• 3️⃣ Deep ulcer + osteomyelitis/abscess
• 4️⃣ Partial gangrene of foot
• 5️⃣ Whole foot gangrene

🔑 Predicts 6-month risk of amputation & mortality.

Diabetic Foot Ulcer Scoring

Grade	Perfusion	Extent	Depth	Infection	Sensation	Score
1	No PAD	Skin intact	Skin intact	None	Normal	0
2	PAD, no CLI	<1 cm²	Superficial	Surface	Loss	1
3	Critical ischaemia	1–3 cm²	Fascia/muscle/tendon	Abscess, fasciitis, septic arthritis	-	2
4	-	>3 cm²	Bone/joint	SIRS	-	3

Management & Preventive Care

• 👣 Routine Foot Checks: Annual (or more often if problems). Teach self-care, daily inspection, avoid tight shoes/rough seams.
• 🩺 Risk Factor Screening: Past ulcer/amputation, ESRD, neuropathy, PAD, smoking.
• 🔍 Examination:
  • Monofilament (10g) for neuropathy.
  • Pulses + ABPI (note: may be falsely high with calcification).
  • Identify ulcer type: neuropathic (plantar), neuroischaemic (toe tips/lateral border).
  • Look for infection (inflammation, pus), deformities (claw toes, Charcot).
• 🟢 Risk Stratification:
  • Low = no risk factors → yearly review.
  • Moderate = one factor → 3–6 monthly.
  • High = multiple/prior ulcer/amputation → 1–2 monthly.
  • Active = ulcer/infection/Charcot → urgent referral.

Referral & Follow-Up

• 🚑 Limb-threatening: immediate acute care referral.
• ⚠️ Urgent: Foot protection team within 1 working day.
• 👣 Moderate/high risk: Specialist foot service within 2–4 weeks.

Emergency Management

• 💊 Infection: IV broad-spectrum antibiotics (Staph/Strep/anaerobes), surgical consult for deep infection/abscess.
• 🦴 Charcot arthropathy: Urgent immobilisation + surgical review.
• 🧼 Foot hygiene: Address nails, tinea, poor footwear, socks.