Hey readers! Welcome once again to my article.
So, In this series I will share some of my cases that I got to see. As an intern doctor, I get posted in almost every department and get to observe new cases. So, Here I am sharing some of my case experiences with you.
Few days back, I was assigned to a case of suspected diabetic foot ulcer. I will talk about this topic in detail later in this article, but first, let me share some of the case information.
Case Introduction.
The case is of 47 year old female.
According to her, She was apparently well, one month back when she noticed a wound over the left great toe. According to her the wound was associated with pain, some tingling sensation and a little bit of discharge. She later explained, the discharge was initially watery and later became thick and foul smelling. Also, she confessed of ignoring the wound and not providing any adequate care. Gradually, the size of wound increased and the skin surrounding the wound became red and painful to touch. She had a history of trauma and she has been diabetic for over 5 years now.
On examination, the wound was about 3 x 4 cm and around 7 cm distal to the ankle joint. The margin of the wound was irregular with sloping edge and scanty foul smelling discharge. The tendon was also visible as you can see in the picture. Some of you might find it gross, so I blurred it a little bit.
As You can see, the wound is quite deep and the white tendon is also visible even though I blurred it a little bit. After observing it, Different samples were collected and wound cleaning was done.
Since, she has a history of diabetes, this was suspected for diabetic foot ulcer. These were some of the investigations recommended for better diagnosis. X-ray to check whether there is any change in alignment of the bones, blood test- glucose level, urine glucose level and color Doppler study for the arteries of the foot.
She is still under observation.
After this short intro, you must have got some idea about what the diabetic ulcer is. Now, let's talk about in detail.
Diabetic Foot Ulcer
It is one of the complications of poorly controlled diabetes. Defined as a break in the skin tissue, exposing the layers underneath it. It mostly affects the pressure areas of the foot, i.e, under the great toe and sole of the foot. In this case you can see, the ulcer is on the upper part, that is because of the direct injury.
According to international diabetes federation, about 6.4% of the diabetic people develop this condition, but, it is preventable in most of the cases with good foot care. Likewise, the treatment also varies according to the cause.
Here are some causes of diabetic foot ulcer.
- Loss of sensation in the foot or toes due to diabetes.
- Poor blood flow.
- Increased pressure on the foot.
- Direct injury (This case)
- Very high blood sugar (hyperglycemia).
Loss of sensation in the foot is due to diabetic neuropathy. The exact cause of this is still unknown. But, it is said that, high blood sugar can damage nerves and interfere with their signal sending ability. This leads to loss of sensation in the high pressure areas in the foot. So, whenever there is a minor injury in the foot area, it goes unnoticed. The wound grows and turns into an ulcer.
Poor blood flow is due to damage to the blood vessels due to high sugar level and also due to diabetic neuropathy as it affects nerve supplying blood vessels too. The blood vessels of the foot thickens and hardens leading to poor blood flow and the ulcer.
Direct injury and high blood sugar at the same time can be very dangerous. As, the high sugar content is a favorable environment for bacterial growth and also delays the process of healing the wound. If there is a direct injury leading to open wounds and high sugar level, it favors the growth of bacterias further deteriorating the wound. The infection can move from skin to bones. If this happens, the bone might need to be amputated. This is why a diabetic person must give extra care to their foot.
Some Identifying symptoms.
If you are a diabetic person, some of the earliest signs is staining your socks and discharge leak in your shoes. Also, other early symptoms are, redness in the feet, swelling and change in odor.
The earliest visible of a serious ulcer is formation of black tissue. This is known as eschar. This is formed due to either of the above mentioned causes. If it is due to poor blood flow, the tissues are essentially dying due to necrosis. If this is due to an infection, you can see some foul smelling discharge. The infection can also lead to partial or complete gangrene formation.
Sometimes, the symptoms are not that serious, but, if you are diabetic, every minor injury on the foot must be taken seriously.
Call your doctor asap, if you notice any black tissue or feel any pain around that tissue on your foot.
Here are the criteria, that a doctor uses to classify the wound. This ranges from grade 0 to 3.
0- No ulcer is present, but the foot is at risk.
1- Ulcer is small without infection
2- Ulcer is deep, exposing tendon without infection.
3- Large ulcer with abscess.
This case comes under grade 3 of the criteria, as the ulcer is a large and abscess discharge is also present.
Some Risk Factors if you are diabetic.
There are some common factors among the diabetics that leads to this condition. If This factor is acknowledged and controlled, then it significantly reduces the risk. Here are some of the factors.
- Improper hygiene of the foot.
- Excessive alcohol.
- Tight shoes and bad quality shoes.
- Improper nail hygiene.
- Neglected diabetes.
- Obesity.
- No awareness
you can see, all of them are completely preventable.
Well, in this case, she confessed of neglected diabetes, and neglecting the wound. Also, you can see the improper hygiene of the foot.
Prevention of diabetic foot.
About, 10% of these patients have to go through amputation therefore, self care is absolutely necessary for the prevention. If you are a diabetic, you have to closely monitor your glucose levels. This keeps the chances of complications low if your levels are under your control.
Also, even after the treatment, diabetic foot can re-occur. Here are some ways that you can consider to prevent this.
- Wash your feet almost every day.
- Wear only comfortable shoes.
- Diabetic patients have dry skin, so keeping it moisturized it only option.
- Trimming and cleaning the toenails, as dirty toenails can lead to infection.
- Changing socks every day.
- If you have callus formation, then you need to get it removed asap.
Even after these steps, if you notice any redness or black tissue formation or numbness in your foot, call your doctor asap.
If these, are ignored and the ulcer progresses to the bones, then the final option of treatment is surgery,
This image is from another case about a month ago. Surgeons had to amputate his toes because of un-treatable infected diabetic ulcer. At this point, Replacement of the lost skin by skin graft is done or if nothing works, amputation is done.
Final words.
If you are able to identify the wound early, then it is completely treatable. If you notice any kind of redness, numbness or tissue formation, see a doctor. The longer you wait, more un-treatable it gets. The un-treatable ulcers are only managed by amputation.
So, if you are provided with some medications by the doctor and you ulcer is healing. You need to give absolute rest to your feet. No pressure should be applied. As, high blood sugar and pressures make the healing process delay.
In the case of infection, aggressive antibiotic therapy is used soon after identifying the bacteria based on microbiological cultures.
Once the ulcer is healed, then you must give proper care and never neglect any minor injury on your feet.
That's it for this article guys. I hope you are now aware about this condition.
*ALL images used belong to me and are copyright free*
References:
[1]https://en.wikipedia.org/wiki/Diabetic_foot
[2]https://medlineplus.gov/diabeticfoot.html
[3]https://www.medicalnewstoday.com/articles/317504#symptoms
[4]https://www.webmd.com/diabetes/foot-problems
My Previous articles:
[1]The Relation between Hypertension and Heart Failure. Ways to prevent it.