Elsevier

Orthopaedics and Trauma

Volume 32, Issue 6, December 2018, Pages 416-422
Orthopaedics and Trauma

Foot and ankle trauma
Diagnosis and management of the acute hot diabetic foot

https://doi.org/10.1016/j.mporth.2018.09.005Get rights and content

Abstract

Diabetes is an increasing problem in the modern world. Along with the rise in prevalence of the disease the number of diabetic complications presenting is increasing and amongst these is diabetic foot issues. Foot infection and Charcot arthropathy are the two key pathologies that present acutely with a hot swollen foot. Both require timely diagnosis and management to prevent disastrous long-term sequelae.

Acutely presenting foot infections are both limb and life threatening and require urgent intervention to improve the chance of limb salvage. The ability to recognize and acutely deal with a diabetic foot requiring urgent surgical drainage is relevant to all orthopaedic surgeons with an on-call commitment and not solely to the foot and ankle specialist.

Charcot arthropathy results in foot deformity that increases the likelihood of future ulceration and infection. The differentiation and acute management of the two conditions will be discussed.

Introduction

Diabetic foot problems are increasing in prevalence due to the rising obesity and incidence of type II diabetes across the world. In 2013 there were 2.9 million people in the UK diagnosed with diabetes and by 2025 this is estimated to have increased to over 5 million people.1 Diabetic patients develop foot problems secondary to peripheral neuropathy, peripheral vascular disease, foot deformities and ulceration all of which can be acute or chronic in nature. Foot ulcers are common in the diabetic population with a 10% lifetime risk of ulceration.1 Ulceration is a major risk factor for developing infection. Acute infections are a major concern because they are associated with a risk of loss of limb and life in severe cases. Peripheral neuropathy masks pain and reduces the patient's awareness of a problem meaning that presentation is often delayed. Clinicians can also be misled into underestimating the severity of the infective process due to patients' apparent comfort combined with a lack of systemic inflammatory response. Once present infection in the diabetic foot can progress rapidly so any delays in presentation or recognition can have major impact on the outcomes. Charcot neuroarthropathy is another cause for an acutely hot inflamed diabetic foot, again recognition is important to protect the shape of the foot and reduce the risk of future ulceration.

Section snippets

Infection

Acutely infected diabetic feet require prompt assessment and appropriate management. Failure to recognize the severity of infection and provide swift treatment results in increased morbidity, limb loss and potentially mortality.2 The term ‘foot attack’ has been adopted to highlight the importance of infection in diabetic feet.2 Similar to myocardial infarction and cerebrovascular accidents where time to treatment is vital to preserve tissue delays in treatment of moderate or severely infected

Acute Charcot

Charcot neuroarthropathy is a destructive joint arthropathy which occurs secondary to peripheral neuropathy. The inability to feel a 5.07/10 g Semmes Weinstein monofilament confirms peripheral neuropathy. Proprioception will also be impaired and there may be reduced vibration sense to a 128 Hz tuning fork. There is often a delay in the diagnosis of Charcot arthropathy with cellulitis or deep vein thrombosis being appointed as the cause. Whenever there is unilateral swelling in a neuropathic

Conclusion

The acute hot diabetic foot requires rapid and aggressive management. The ‘foot attack’ with spreading deep infection must be recognized and emergently drained. Delays for further imaging, revascularization or specialist foot and ankle surgeon opinion risks deterioration with the resultant loss of limb or life and must be avoided in all instances. The ongoing care of diabetic foot infection is complex requiring a multidisciplinary effort. Delayed diagnosis in Charcot arthropathy increase the

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