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The diabetic footClassification of the diabetic foot. Diabetic foot ulcers
- Classification of the diabetic foot
- Diabetic foot ulcers
The diabetic foot is a very frequent complication among people with diabetes and consists of the set of infection, ulceration and / or destruction of the deep tissues accompanied by neurological disorders and various stages of insufficient blood circulation in the lower limbs. The ailments affecting the feet can remain latent for many years and then present themselves with all their arrogance, but fortunately they can be diagnosed early with simple analyzes that can be performed at the general practitioner's surgery or at the nearest center of diabetology.
Not all diabetics inevitably develop foot-related diseases, even if a person with a 25-year history of diabetic disease, for example, has significant chances of experiencing neurological and circulatory changes.
Good glycemic compensation is essential for the prevention of long-term complications. Many times people with diabetes do not understand the importance of a healthy lifestyle, diet and blood sugar normalization with drug therapy. A constantly high blood sugar (hyperglycaemia) does not create problems immediately and therefore patients tend to underestimate the disorder; unfortunately, however, high blood sugar levels for prolonged periods are at the origin of a series of serious problems and, moreover, delay the healing of ulcers, if any.
Hyperglycaemia damages nerves and blood vessels affecting certain target organs such as: brain, heart, kidneys, eyes and especially the feet.
The ulcers affecting the feet are usually accompanied by a series of other well-defined symptoms: nerve diseases (neuropathy), poor blood supply (arteriopathy), deformity of the bone structure and associated trauma. Since foot ulcers in diabetic people are responsible for most of the leg amputations, the preventive interventions aim to break down, or at least reduce, this tragic consequence.
Another trigger is represented by shoes: they are in fact responsible for the vast majority of traumatic foot injuries (calluses, blisters, ulcers) and related complications.
The active participation of patients in the prevention and treatment process is required to keep the evolution of the disease under control.
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Classification of the diabetic foot
The diabetic's foot can be classified according to the type of problem that afflicts it: if only neuropathy is present it is defined as neuropathic foot, if only ischemia is present it is defined as ischemic foot, in the presence of both pathologies, finally, it is defined piedeneuroischemico. The neuropathic foot is characterized by the presence of one of three possible forms of neuropathy: sensory, motor, autonomic.
Sensory neuropathy is manifested by the insensitivity of the foot to external stimuli (the sensory nerves are affected), for example the subject can walk all day with a stone in the shoe and not notice anything, or have very tight shoes and do not feel minimally constriction; this alteration is the most dangerous, since in the absence of pain as an alarm bell, the relative defensive response also ceases. This disorder can be diagnosed with a simple small tool called monofilament.
The monofilament consists of a tiny device equipped with a semi-rigid plastic wire that bends when a pressure of about 10 g is exerted on the skin of the foot.
If the patient is able to feel this stimulus at least in four points, the presence of sensory neuropathy can be excluded; otherwise the diagnosis will favor an insensitivity to stimuli.
Another easy test is the use of the tuning fork in order to evaluate the perception of vibration (vibratory threshold).
The tuning fork is vibrated and placed on the first finger (big toe) and on the malleolus. If the patient does not perceive the vibration produced by the instrument, it means that there are problems with the nerve pathways.
Motor neuropathy causes an imbalance between the flexor and extensor muscles which over time causes torsion of the skeletal system and deformity of the foot. The origin is a decrease in the strength and size of the muscles (hypotonia and hypotrophy). These imbalances determine characteristic deformities of the fingers and small joints, as well as of the plantar vault. The deformation of the normal bone structure causes exaggerated pressures on small points of the foot giving rise to the formation of calluses. Calluses (hyperkeratosis) behave like foreign bodies that push on deep bone structures, causing bleeding and bacterial invasion. This evolution is particularly risky for diabetics. The calluses must be removed by expert personnel and after removal it is necessary to make a suitable shoe to redistribute the weight on the entire foot and unload the areas at risk.
To evaluate plantar hyperpressure, special podobarometric platforms are used, which accurately measure the distribution of weight on the foot; these platforms can be computerized or manual.
Autonomic neuropathy produces an imbalance in the secretion of the sweat and sebaceous glands, with consequent dryness of the skin (anhidrosis) and predisposition to cuts and skin infections. Swelling of the leg (edema) can also be caused by this disease. Among the less frequent lesions there is a form of damage to the bones, found in subjects with neuropathy (neuroarthropathy), called Charcot foot.
This disease creates a subversion of the foot's bone structure with ligament sagging and muscle weakness; the result is the collapse of the plantar vault with a characteristic rocking foot.
This disorder must be recognized promptly, as it requires a particular approach.
The ischemic foot is the consequence of the non-flow of blood to the extremities (ischemia). Symptoms are related to the severity of ischemia and may include: difficulty walking due to pain in the calf (claudication), purple coloring of the feet, very cold skin and intense pain especially when the leg is stretched out (in bed); in the advanced stage black ulcers are formed on the fingers (eschar), which are the expression of the complete closure of the arteries. Usually this disease affects both legs and occurs mainly from the knee down.
Diagnosis is made on the basis of simple tests. The first necessary examination is the evaluation of the peripheral wrists. The pulsations can be detected with the fingers or better still with the use of a portable Doppler device. In medical clinics a simple examination is carried out, called measurement of the Winsor index, which consists in detecting the pressure in the ankle.
It is a very precise detection procedure, capable of identifying the subjects for which greater diagnostic insights are needed.
Finally, the neuroischemic foot presents simultaneously the symptoms of neuropathy and ischemia; these two ailments, when they occur together, worsen the whole picture.
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