Diagnosis of the diabetic foot

Early diagnosis of initial signs of damage to the peripheral nervous system, vascular system, soft tissues and bone structures of the lower limbs is aimed at preventing amputations in patients. Diabetes mellitus.

To conduct an initial diagnostic search, it is often sufficient to have a general clinical study and a minimal set of instrumental diagnostic methods that help determine - the state of peripheral innervation and the main arterial blood flow.

Mandatory survey methods in outpatient settings:

• collection of complaints and anamnesis;
• examination and palpation of the lower limbs;
• definition of pain, tactile, temperature and vibration sensitivity;
• definition of LPI;
• bacteriological examination of pane exudate and ulcerative defect tissues with the determination of the microbial spectrum and the sensitivity of microorganisms to antibacterial agents;
• general clinical and biochemical blood tests;
• coagulogram;
• X-ray of the foot in the presence of ulcerative defect, swelling, hyperemia.

Diagnostic search should begin with clarifying the patient's complaints and collecting anamnesis. Attention should be paid to such complaints as pain in the legs, their nature and connection with physical activity, chilliness of feet and paresthesia, edema of the lower extremities, subjective manifestations of decompensation of carbohydrate metabolism, fever, ulcerative defects and deformities of the feet and ankles. When collecting anamnesis, special attention should be given to the duration and nature of the course of the underlying disease, the presence of ulcerative foot and shin defects in the past, possible concomitant diseases affecting the development of the diabetic foot syndrome. Important family history of the patient, the conditions of his life at the moment. Already on the basis of complaints and anamnesis, you can make a first impression about that. Whether the patient is at risk for developing the diabetic foot syndrome.

The most common complaints of diabetic foot syndrome are the following complaints

• numbness of fingers and feet;
• pain (most often mild, but causes a feeling of anxiety and fear in the patient);
• weakness and fatigue in the legs;
• cramps in the calf muscles;
• paresthesia;
• change the shape of the feet.

The next stage of diagnostic search is the examination of the patient's lower limbs in a well-lit room. Not only the rear, but also the plantar surface of the feet, the interdigital spaces must be inspected. Examination and palpation of the lower extremities will allow the doctor to comprehend the presence of deformations and their nature, color, turgor and skin temperature, the presence of ulcerative defects, their size, localization and condition of surrounding tissues, pulsations of peripheral arteries.

To assess the degree of severity of distal pelinhropathy, various types of sensitivity are examined. To this end, the following tools are used:

• to assess the tactile sensitivity - a monofilament weighing 10 g;
• for the assessment of vibration sensitivity - graduated tuning fork;
• to assess the temperature sensitivity - two glass tubes filled with warm and cold water, or a cylinder made of two materials having a constant temperature difference ("type-term").

The absence of pulsation on the arteries of the feet during palpation dictates the need for ultrasonic dopplerometry with LIP measurement using a portable Doppler device and a sphygmomanometer. The manometer cuff is superimposed on the middle third of the shin. The sensor of the Doppler apparatus is installed at the projection point of the posterior tibial artery or the rear artery of the foot. Systolic blood pressure is measured in one of the listed arteries. Then, according to the standard procedure, systolic blood pressure and brachial artery are measured. LPI is calculated as the ratio of the systolic blood pressure in the artery of the lower limb to the magnitude of systolic blood pressure in the brachial artery. Normally, the LPI is 0.8-1. Decrease in this indicator below 0.8 indicates the patient has an obliterating disease of the lower limb arteries. The elevation of LPI to 1.2 and higher indicates a marked diabetic neuropathy and medikalcinosis of Monkeberg.

Assessment of the state of bone structures of the foot and detection of signs of diabetic osteoarthropathy are based on the radiography of feet and ankles. For more information, the X-ray of the feet is carried out in two projections; direct and lateral.

Compulsory methods of examination in the conditions of a specialized hospital:

• collection of complaints and anamnesis;
• examination and palpation of the lower limbs
• definition of pain, tactile, temperature and vibration sensitivity;
• definition of LPI;
• bacteriological study of wound exudate and ulcerative tissue defects with determination of microbial spectrum and sensitivity of microorganisms to antibacterial agents;
• determination of the size and depth of the ulcerative defect;
• duplex scanning of arteries with determination of degree and extent of occlusive lesion (in the choice of the method of vascular reconstruction - radiopaque angiography);
• percutaneous determination of oxygen saturation of tissues (oximetry) of detection of ischemia and degree of its severity;
• X-ray, computed tomography and / or magnetic resonance imaging (MRI) of the lower limb bone structures to detect signs of osteomyelitis, the presence of a deep infectious process in the foot tissues;
• general clinical and biochemical blood tests (lipid spectrum, total protein, albumin, creatinine, potassium, alkaline phosphatase, ionized calcium, bone isoenzyme of alkaline phosphatase) determining the severity of atherosclerotic process, diabetic nephropathy, bone resorption and osteosynthesis;
• coagulogram,
• assessment of the status of the fundus.

To determine the degree of severity of the diabetic foot syndrome, it is important to estimate the depth of the ulcerative defect, the presence of cavities, and the condition of the surrounding tissues. To do this, it is necessary to measure the area and depth of the trophic ulcer, to carry out bacteriological examination of wound detachable and soft tissues. The material for the study should be taken not from the surface of the ulcerative defect, but from the depth of the affected tissues.

To carry out a qualified study, the rules for the collection and transport of material must be carefully observed.

The presence of lesions of bone structures in patients with various clinical forms of the diabetic foot syndrome determines the urgency of conducting a survey aimed at verifying the genesis of bone pathology and determining the tactics of its treatment. For this, in addition to traditional radiography, it is possible to perform MRI, CT, osteoscintigraphy.

The pronounced deformity of the feet in patients with diabetic osteoarthropathy leads to the formation of abnormal areas of excessive loading pressure on the plantar surface. The identification of sites is very important for the development of measures to prevent the recurrence of ulcerative defects. The method of computer pedobarography allows you to choose the right orthopedic devices and evaluate the effectiveness of their application.

Differential diagnosis of diabetic foot syndrome

Differential diagnosis, usually carried out between ischemic and angiopathic ulcers. Ulcers of non-diabetic genesis do not have a typical localization, not associated with areas of excessive pressure on the foot. In addition to diabetes, neuro-osteoarthropathy occurs in certain systemic diseases: tertiary syphilis, syringomyelia, leprosy.

[1], [2], [3], [4], [5], [6], [7], [8]