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Piciorul diabetic

Picior diabetic infecia, ulceraia i/sau distrucia


esuturilor profunde, asociat cu anomalii neurologice i cu
boal vascular periferic n diferite grade la nivelul
membrelor inferioare.

Boal vascular periferic prezena semnelor


clinice ca absena pulsului la pedioase, istoric de claudicaie
intermitent, durerea n repaus i/sau anomalii la
investigarea vascular non-invaziv indicnd alterarea
circulaiei.
Consencul Internaional privind Piciorul Diabetic, 1999

Factori etiologici n patogenia piciorului


diabetic
microangiopatie

macroangiopatie
scleroza
Monckeberg

traumatism

Picior diabetic
infecie

polineuropatie

osteoartropatia

modificri
structurale

Combination of:
- lack of sensation
- limited joint mobility
- autonomic dysfunction resulting in dry
skin
- repetitive high pressure

callus formation
increase the foot pressure
plantar ulceration at the
site of maximum pressure
Boulton AJM et al. Neuropathic Diabetic Foot Ulcers. N Engl J Med 2004;351:48-55

Sudomotor dysfunction

impairment of the sympathetic innervation of cutaneous sweat


glands
autosympathectomy

reduction/loss of sweating - anhidrosis


primarily on the lower extremities
dryness of the skin may lead to fissure formation, cracks
portals of entry for
microorganisms

Infectious ulcers

Vinik AI et al. Diabetic Autonomic Neuropathy. Semin Neurol 2003;23(4):365-372.


Kempler P (ed). Neuropathies. Nerve dysfunction of diabetic and other origin. 1996

Clasificarea Meggitt-Wagner a
piciorului diabetic
Grad 0 fara ulcer, dar cu risc inalt
Grad 1 ulcer superficial
Grad 2 ulcer adanc, extins la tendoane, dar nu
implica osul
Grad 3 ulcer adanc, implica osul, osteomielita
Grad 4 gangrena localizata
Grad 5 gangrena a intregului picior

UNIVERSITY OF TEXAS CLASSIFICATION OF DIABETIC FOOT


GRADE-0

GRADE-1

GRADE-2

GRADE-3

Preulcerative or
Wound
Superficial wound, not
Wound
STAGEpostulcerative
penetrating to
involving tendon,
penetrating to
A
lesion completely
tendon or
capsule or bone
bone or joint
epithelialized
capsule
STAGE-B

Infection

Infection

Infection

Infection

STAGE-C

Ischemia

Ischemia

Ischemia

Ischemia

STAGED

Infection and
Ischemia

Infection and Ischemia

Infection and Infection and


Ischemia
Ischemia

La inspectie
Cauta orice
modificare osoasa
cunoscand
principalele
modificari de la
nivelul piciorului.

DiabeticFoot Ulcers:Prevention,
Diagnostic and Clasification
(14).Locatiile frecvente ale ulceratiilor
la nivelul piciorului

Aspecte ale piciorului diabetic


Deformarile osoase
predispun anumite
zone la ulceratii

Figure 3. Structural deformity. When combined with sensory


neuropathy, a structural foot deformity may predispose the
diabetic patient to ulceration, infection and subsequent
amputation.

Figure 4. Neuropathic ulceration of the foot in a diabetic patient

Picior Charcot

Examinare picior

Examen vascular
periferic:
palpare puls arterial;
examinare circulatie
venoasa;
culoare tegumente
T tegumente

Examen neurologic:
Testare sensibilitate

- tactila
- termica
- dureroasa
ROT

Diabetic foot disorders; American College of Foot and Ankle

Zonele de testare a sensibilitatii

Testarea
sensibilitatii cu
monofilament - la
presiune

DiabeticFoot Ulcers:Prevention, Diagnostic


and Clasification

Alte teste de sensibilitate

intepare

Sensibilitatea tactila

Cu fire de bumbac
sau cu vata

Perceptia vibratiilor

Cu diapazon

RECOMANDARI
R. Inspectia piciorului se recomanda la fiecare vizita
iar examinarea completa anual.
R. Testarea sensibilitatii periferice la bolnavul cu diabet
se face anual.
R. Se recomanda un controlul agresiv al glicemiei
pentru a reduce riscul aparitiei piciorului diabetic.
R. Pacientul trebuie invatat sa-si examineze piciorul si
sa-l ingrijeasca.
R. Trimite la chirurg, ortoped, dermatolog la aparitia
unei rani, infectii, onicomicoze.