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Diabetic Foot Annual Review Glos Care Pathway Overview

All patients with Diabetes should receive education and advice in foot care, to reduce the incidence of acute and chronic ulceration and potential amputation.

A foot examination should be performed annually for the patient with Diabetes by a trained Health Care Professional, therefore this pathway outlines the ‘suggested’ criteria that a Full Diabetes Foot Assessment should include and associated management of both acute and chronic foot problems.

Please click the relevant flowchart box to be taken directly to textual information

Red Flags
UNWELL PATIENT WITH:
  • Ulceration with spreading infection or signs of sepsis.
Or
  • Clinical concern of a deep-seated soft tissue or bone infection
  • Critical limb ischaemia with infection
  • Wet gangrene
  • Cold pulseless foot
ADMIT DIRECT VIA EMERGENCY DEPARTMENT
Diabetic Foot Assessment

Diabetic Foot Assessment should include:

Check:

  • Skin Colour
  • Skin Quality
  • Temperature of both feet
  • Palpate Dorsalis Pedis and Posterior Tibial pulses in both feet
  • Capillary Refill Time

Minimum Standard – Palpate Dorsalis Pedis and Posterior Tibial Pulses

 

Vascular Insufficiency:

  • Dependent rubor
  • Cyanotic colour and cool temperature
  • Pulses monophasic with Doppler
  • Capillary refill time of more than 3 seconds
  • Symptoms of intermittent claudication

  • Use 10g Monofilament in 5 standard nerve sites over both feet,  to check sensory perception

Minimum Standard – use of 10g Monofilament

If equipment available:-

 

  • Check pain perception using Neurotip (hallux)
  • Check vibration perception with tuning fork in hallux and medial ankle joints

Neuropathy indicated:

  • If 2 or more sites are not detected with the 10g monofilament
  • Vibration perception not felt
  • Unable to differentiate between blunt/sharp (use neurotip and 10g monofilament)
Low Risk

  • Protective sensation intact
  • Normal vascular supply 
  • No other risk factors except non -pathological callus alone

  • Agree management plan with Patient with advice on self- care, warning signs of infection and how to access emergency foot care advice.
  • Patients should be made aware of their Risk Status and that they could progress to moderate or even high.
  • Offer structured education at diagnosis, with annual review and reinforcement.
  • Primary Care Annual Review
Moderate Risk

  • Neuropathy

OR

  • Non-critical limb Ischaemia

OR

  • Deformity

Consider Other Risk Factors (below)

  • Patients should be made aware that they are Moderate Risk of foot ulceration.
  • Provide  patient information about foot emergencies and who to contact.
  • Refer to Diabetes Podiatry Foot Protection Team using the Standard Referral Form for assessment and review.

 

Other Risk Factors to consider
  • Poor Glycaemic control
  • Visual Impairment
  • Smoking
  • Arthritis
  • Inability to check feet for any problems
  • Inability to maintain personal hygiene
  • Learning Difficulties
  • Living alone/no carer
  • Ill-fitting footwear
High Risk

Neuropathy AND Non-critical limb ischaemia

Or

  • Neuropathy in combination with significant callus and/or deformity

Or

  • Non-critical limb Ischaemia in combination with significant callus and/or deformity

Or

  • Previous Ulceration

Or

  • Previous Amputation

Or

  • Renal replacement Therapy

Significant callus is defined as 'Callus that requires Podiatric Management' (Scottish Diabetes Group - Foot Action Group 2010).

Significant callus causes pressure on the underlying tissues which can result in the tissues breaking down and an ulcer developing. If a patient has significant callus and is not attending a podiatrist then they should be referred to have a treatment/management plan agreed and introduced to suit their needs.

Non significant callus can be described as callus that does not require podiatric treatment, does not pose any risk and can be treated/managed by the patient.

Structural abnormality of the foot is defined as 'A change in foot shape that resulted in a difficulty in fitting shoes which could be purchased in high street shops'. (Scottish Diabetes Group – Foot Action Group 2010).

non significant structural abnormality of the foot can be described as a very minor change of shape of the foot which does not result in areas of pressure, leading to callus formation, and a difficulty in fitting shoes which could be purchased in high street shops.

  • Patients should be made aware that they are High Risk of foot ulceration.
  • Provide patient information about foot emergencies and who to contact.
  • Refer to Diabetes Podiatry Foot Protection Team using the Standard Referral Form for assessment and review.
Ulcerative Foot (Active Diabetic Foot Problem)

​Ulcerate Foot (Active Diabetic Foot Problem):
  • Active ulceration
  • Localised infection

OR

  • Limb ischaemia

OR

  • Stable, dry gangrene

OR

  • Unexplained hot, red swollen foot with or without pain (suspected charcot)

Management of Charcot Foot

“Charcot foot is a neuroarthropathic process with osteoporosis, fracture, acute inflammation and disorganisation of foot architecture.”

“Suspect acute Charcot Arthropathy if there is redness, warmth, swelling or deformity (in particular, when the skin is intact) especially in the presence of peripheral neuropathy or renal failure. Think about acute Charcot Arthropathy even when deformity is not present or pain is not reported”. (NICE NG19 updated January 2016)

Diagnosis should be made by clinical examination” (Frykberg et al. 2000)

  • Good blood supply to lower limb with neuropathy present
  • Observe foot for obvious signs of trauma and / or cellulitis
  • Heat differentiation between limbs – affected limb often 2-8 degrees higher than other foot.
  • History of trauma to limb may be apparent
  • X ray for baseline and to exclude diabetic neuropathic fracture
  • Differential diagnosis: Infection

Refer people with suspected Charcot Foot to a multidisciplinary foot care team for immobilisation of the affected joint(s) and for long term management to prevent ulceration” (NICE 2015 updated January 2016)

  • Offer treatment with a non-removable offloading device
  • Pressure relieving footwear to be worn until inflammation settles, heat differentiation disappears and bone activity reduces (SIGN 2001)
  • Refer to Orthopaedic surgeon for assessment and discussion of appropriate surgical intervention
  • Discontinue treatment when foot temperature is equal.

Use Podiatry Urgent Diabetic Foot Referral Form and email to podiatry.appointments@glos-care.nhs.uk

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