Diabetic foot: Difference between revisions
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==Diagnosis== | ==Diagnosis== | ||
The signs of underlying [[osteomyelitis]] are "an ulcer area larger than 2 cm<sup>2</sup>, a positive probe-to-bone test result, an erythrocyte sedimentation rate of more than 70 mm/h, and an abnormal plain radiograph" according to a [[systematic review]] by the [http://www.sgim.org/clinexam-rce.cfm Rational Clinical Examination].<ref>Sonia Butalia et al., “[http://jama.ama-assn.org/cgi/content/abstract/299/7/806 Does This Patient With Diabetes Have Osteomyelitis of the Lower Extremity?],” JAMA 299, no. 7 (February 20, 2008): 806-813.</ref> A normal [[magnetic resonance imaging]] makes [[osteomyelitis]] unlikely. | The signs of underlying [[osteomyelitis]] are "an ulcer area larger than 2 cm<sup>2</sup>, a positive probe-to-bone test result, an erythrocyte sedimentation rate of more than 70 mm/h, and an abnormal plain radiograph" according to a [[systematic review]] by the [http://www.sgim.org/clinexam-rce.cfm Rational Clinical Examination].<ref>Sonia Butalia et al., “[http://jama.ama-assn.org/cgi/content/abstract/299/7/806 Does This Patient With Diabetes Have Osteomyelitis of the Lower Extremity?],” JAMA 299, no. 7 (February 20, 2008): 806-813.</ref> A normal [[magnetic resonance imaging]] makes [[osteomyelitis]] unlikely. | ||
The [[National Institute for Health and Clinical Excellence]] (NICE) has addressed screening and recommends annually:<ref>(2004) [http://guidance.nice.org.uk/CG10/Guidance/pdf/English CG10 Type 2 diabetes - footcare]. National Institute for Health and Clinical Excellence</ref><br/> | |||
[[Physical examination]] of patients’ feet: | |||
* testing of foot sensation using a 10 g monofilament or vibration | |||
* palpation of foot pulses | |||
* inspection of any foot deformity and footwear | |||
Although NICE and others<ref name="pmid15644549">{{cite journal| author=Singh N, Armstrong DG, Lipsky BA| title=Preventing foot ulcers in patients with diabetes. | journal=JAMA | year= 2005 | volume= 293 | issue= 2 | pages= 217-28 | pmid=15644549 | |||
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=15644549 | doi=10.1001/jama.293.2.217 }}</ref> have recommended monofilament testing, its contribution in the major [[randomized controlled trial]]s is not clear.<ref name="pmid8498761">{{cite journal| author=Litzelman DK, Slemenda CW, Langefeld CD, Hays LM, Welch MA, Bild DE et al.| title=Reduction of lower extremity clinical abnormalities in patients with non-insulin-dependent diabetes mellitus. A randomized, controlled trial. | journal=Ann Intern Med | year= 1993 | volume= 119 | issue= 1 | pages= 36-41 | pmid=8498761 | |||
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=8498761 }}</ref><ref name="pmid12020336">{{cite journal| author=Reiber GE, Smith DG, Wallace C, Sullivan K, Hayes S, Vath C et al.| title=Effect of therapeutic footwear on foot reulceration in patients with diabetes: a randomized controlled trial. | journal=JAMA | year= 2002 | volume= 287 | issue= 19 | pages= 2552-8 | pmid=12020336 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12020336 }} </ref> | |||
{{Image|Footscreensites-rgb.jpg|right|350px|Monofilament testing for diabetic neuropathy using preferred testing locations colored green.<ref name="pmid19595541">{{cite journal| author=Feng Y, Schlösser FJ, Sumpio BE| title=The Semmes Weinstein monofilament examination as a screening tool for diabetic peripheral neuropathy. | journal=J Vasc Surg | year= 2009 | volume= 50 | issue= 3 | pages= 675-82, 682.e1 | pmid=19595541 | |||
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=19595541 | doi=10.1016/j.jvs.2009.05.017 }}</ref>}} | |||
If screening with the monofilament is done, a three site test of the plantar surfaces of the great toe, the third metatarsal, and the fifth metatarsalsis is adequate according to a [[systematic review]]<ref name="pmid19595541">{{cite journal| author=Feng Y, Schlösser FJ, Sumpio BE| title=The Semmes Weinstein monofilament examination as a screening tool for diabetic peripheral neuropathy. | journal=J Vasc Surg | year= 2009 | volume= 50 | issue= 3 | pages= 675-82, 682.e1 | pmid=19595541 | |||
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=19595541 | doi=10.1016/j.jvs.2009.05.017 }}</ref> of studies<ref name="pmid10417599">{{cite journal| author=Smieja M, Hunt DL, Edelman D, Etchells E, Cornuz J, Simel DL| title=Clinical examination for the detection of protective sensation in the feet of diabetic patients. International Cooperative Group for Clinical Examination Research. | journal=J Gen Intern Med | year= 1999 | volume= 14 | issue= 7 | pages= 418-24 | pmid=10417599 | |||
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=10417599 | pmc=PMC1496604 }}</ref>. Another [[systemic review]] questions the test accuracy of the monofilament exam.<ref name="pmid19901316">{{cite journal| author=Dros J, Wewerinke A, Bindels PJ, van Weert HC| title=Accuracy of monofilament testing to diagnose peripheral neuropathy: a systematic review. | journal=Ann Fam Med | year= 2009 Nov-Dec | volume= 7 | issue= 6 | pages= 555-8 | pmid=19901316 | |||
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&retmode=ref&cmd=prlinks&id=19901316 | doi=10.1370/afm.1016 | pmc=PMC2775618 }}</ref> | |||
The role of patient education in preventing ulcers is not clear according to the [[Cochrane Collaboration]]. <ref name="pmid20464718">{{cite journal| author=Dorresteijn JA, Kriegsman DM, Assendelft WJ, Valk GD| title=Patient education for preventing diabetic foot ulceration. | journal=Cochrane Database Syst Rev | year= 2010 | volume= | issue= 5 | pages= CD001488 | pmid=20464718 | doi=10.1002/14651858.CD001488.pub3 | pmc= | url= }} </ref> | |||
==References== | ==References== | ||
<references/> | <references/> | ||
Revision as of 09:48, 28 October 2010
The diabetic foot is "common foot problems in persons with diabetes mellitus, caused by any combination of factors such as diabetic neuropathies; peripheral vascular diseases; and infection. With the loss of sensation and poor circulation, injuries and infections often lead to severe foot ulceration, gangrene and amputation."[1]
Diagnosis
The signs of underlying osteomyelitis are "an ulcer area larger than 2 cm2, a positive probe-to-bone test result, an erythrocyte sedimentation rate of more than 70 mm/h, and an abnormal plain radiograph" according to a systematic review by the Rational Clinical Examination.[2] A normal magnetic resonance imaging makes osteomyelitis unlikely.
The National Institute for Health and Clinical Excellence (NICE) has addressed screening and recommends annually:[3]
Physical examination of patients’ feet:
- testing of foot sensation using a 10 g monofilament or vibration
- palpation of foot pulses
- inspection of any foot deformity and footwear
Although NICE and others[4] have recommended monofilament testing, its contribution in the major randomized controlled trials is not clear.[5][6]
Monofilament testing for diabetic neuropathy using preferred testing locations colored green.[7]
If screening with the monofilament is done, a three site test of the plantar surfaces of the great toe, the third metatarsal, and the fifth metatarsalsis is adequate according to a systematic review[7] of studies[8]. Another systemic review questions the test accuracy of the monofilament exam.[9]
The role of patient education in preventing ulcers is not clear according to the Cochrane Collaboration. [10]
References
- ↑ Anonymous (2024), Diabetic foot (English). Medical Subject Headings. U.S. National Library of Medicine.
- ↑ Sonia Butalia et al., “Does This Patient With Diabetes Have Osteomyelitis of the Lower Extremity?,” JAMA 299, no. 7 (February 20, 2008): 806-813.
- ↑ (2004) CG10 Type 2 diabetes - footcare. National Institute for Health and Clinical Excellence
- ↑ Singh N, Armstrong DG, Lipsky BA (2005). "Preventing foot ulcers in patients with diabetes.". JAMA 293 (2): 217-28. DOI:10.1001/jama.293.2.217. PMID 15644549. Research Blogging.
- ↑ Litzelman DK, Slemenda CW, Langefeld CD, Hays LM, Welch MA, Bild DE et al. (1993). "Reduction of lower extremity clinical abnormalities in patients with non-insulin-dependent diabetes mellitus. A randomized, controlled trial.". Ann Intern Med 119 (1): 36-41. PMID 8498761.
- ↑ Reiber GE, Smith DG, Wallace C, Sullivan K, Hayes S, Vath C et al. (2002). "Effect of therapeutic footwear on foot reulceration in patients with diabetes: a randomized controlled trial.". JAMA 287 (19): 2552-8. PMID 12020336. [e]
- ↑ 7.0 7.1 Feng Y, Schlösser FJ, Sumpio BE (2009). "The Semmes Weinstein monofilament examination as a screening tool for diabetic peripheral neuropathy.". J Vasc Surg 50 (3): 675-82, 682.e1. DOI:10.1016/j.jvs.2009.05.017. PMID 19595541. Research Blogging.
- ↑ Smieja M, Hunt DL, Edelman D, Etchells E, Cornuz J, Simel DL (1999). "Clinical examination for the detection of protective sensation in the feet of diabetic patients. International Cooperative Group for Clinical Examination Research.". J Gen Intern Med 14 (7): 418-24. PMID 10417599. PMC PMC1496604.
- ↑ Dros J, Wewerinke A, Bindels PJ, van Weert HC (2009 Nov-Dec). "Accuracy of monofilament testing to diagnose peripheral neuropathy: a systematic review.". Ann Fam Med 7 (6): 555-8. DOI:10.1370/afm.1016. PMID 19901316. PMC PMC2775618. Research Blogging.
- ↑ Dorresteijn JA, Kriegsman DM, Assendelft WJ, Valk GD (2010). "Patient education for preventing diabetic foot ulceration.". Cochrane Database Syst Rev (5): CD001488. DOI:10.1002/14651858.CD001488.pub3. PMID 20464718. Research Blogging.