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Mirkin Foot menu
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| Diabetic Foot Care |
Diabetes and your feet |
According to the American Diabetes Association, about 15.7 million
people (5.9 percent of the United States population) have diabetes.
Nervous system damage (also called neuropathy) affects about 60 to
70 percent of people with diabetes and is a major complication that
may cause diabetics to lose feeling in their feet or hands. |
Foot problems are a big risk in diabetics. Diabetics must constantly
monitor their feet or face severe consequences, including amputation.
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With a diabetic foot, a wound as small as a blister from wearing a
shoe that`s too tight can cause a lot of damage. Diabetes decreases
blood flow, so injuries are slow to heal. When your wound is not healing,
it`s at risk for infection. As a diabetic, your infections spread
quickly. If you have diabetes, you should inspect your feet every
day. Look for puncture wounds, bruises, pressure areas, redness, warmth,
blisters, ulcers, scratches, cuts and nail problems. Get someone to
help you, or use a mirror. |
Here`s some basic advice for taking care of your feet: |
• Always keep your feet warm.
• Don`t get your feet wet in snow or rain.
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Don`t put your feet on radiators or in front of the fireplace.
• Don`t smoke or sit cross-legged. Both decrease blood supply
to your feet.
• Don`t soak your feet.
• Don`t
use antiseptic solutions, drugstore medications, heating pads or sharp
instruments on your feet.
• Trim your toenails straight
across. Avoid cutting the corners. Use a nail file or emery board.
If you find an ingrown toenail, contact our office.
• Use
quality lotion to keep the skin of your feet soft and moist, but don`t
put any lotion between your toes.
• Wash your feet every
day with mild soap and warm water.
• Wear loose socks to
bed.
• Wear warm socks and shoes in winter.
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When drying your feet, pat each foot with a towel and be careful between
your toes.
• Buy shoes that are comfortable without a "breaking
in" period. Check how your shoe fits in width, length, back,
bottom of heel, and sole. Avoid pointed-toe styles and high heels.
Try to get shoes made with leather upper material and deep toe boxes.
Wear new shoes for only two hours or less at a time. Don`t wear the
same pair everyday. Inspect the inside of each shoe before putting
it on. Don`t lace your shoes too tightly or loosely.
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Choose socks and stockings carefully. Wear clean, dry socks every
day. Avoid socks with holes or wrinkles. Thin cotton socks are more
absorbent for summer wear. Square-toes socks will not squeeze your
toes. Avoid stockings with elastic tops.
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When your feet become numb, they are at risk for becoming deformed.
One way this happens is through ulcers. Open sores may become infected.
Another way is the bone condition Charcot (pronounced "sharko")
foot. This is one of the most serious foot problems you can face.
It warps the shape of your foot when your bones fracture and disintegrate,
and yet you continue to walk on it because it doesn`t hurt. Diabetic
foot ulcers and early phases of Charcot fractures can be treated with
a total contact cast. |
The shape of your foot molds the cast. It lets your ulcer heal by
distributing weight and relieving pressure. If you have Charcot foot,
the cast controls your foot`s movement and supports its contours if
you don`t put any weight on it. To use a total contact cast, you need
good blood flow in your foot. The cast is changed every week or two
until your foot heals. A custom-walking boot is an another way to
treat your Charcot foot. It supports the foot until all the swelling
goes down, which can take as long as a year. You should keep from
putting your weight on the Charcot foot. Surgery is considered if
your deformity is too severe for a brace or shoe. |
Foot Ulcers and the Total Contact Cast |
The diabetic foot is prone to major problems. This is because the
foot is the "organ" that expresses many of the underlying
effects of diabetes. These are: (1) neuropathy, (2) vascular disease,
and (3) diminished response to infection. |
As a result of the neuropathy, the foot can become deformed. This
happens through two routes or reasons. The first is that the neuropathy
causes paralysis of small muscles in the foot, which results in clawing
of the toes. Clawing of the toes causes prominence of the metatarsal
heads on the bottom of the foot as well as the knuckles on the dorsum
or top of the foot. The neuropathy also causes diminished sensation.
As the prominent metatarsal heads on the plantar or bottom of the
foot are subjected to increased pressure, the skin will begin to hypertrophy
and become callused. The callused skin can be subjected to shear forces.
The forces will cause a separation between the layers of the skin,
which will fill with fluid, which can then become contaminated and
infected. The pressure can also cause primary breakdown of the skin
in these areas, and the result is a foot ulcer. Once the initial breakdown
and contamination occurs, the foot then can go on to significant problems
because of infection. |
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The second route to deformity is through the process known as the
Charcot foot. In this situation, because of the neuropathy or lack
of protective sensation, bones in the foot subjected to microscopic
trauma will actually fracture and disintegrate. The foot, then subjected
to the stresses of ambulation, will become deformed. Often, this is
in the shape of a rocker, causing prominence of bone in the middle
portion of the foot rather than the metatarsal heads. The prominence
in the middle portion of the foot is then prone to cause ulceration
along the same mechanism that has just bee described. |
The total contact cast is a casting technique that is used to heal
diabetic foot ulcers and to protect the foot during the early phases
of Charcot fracture dislocations. The cast is used to heal diabetic
foot ulcers by distributing weight along the entire plantar aspect
of the foot. It is applied in such a way to intimately contact the
exact contour of the foot; hence, the designation "total contact
cast." |
By relieving the bony prominent areas of pressure, the ulcers are
permitted to heal if the cast is applied in such a way that the patient
can remain ambulatory during the treatment of the ulcer. The principle
involved here is that the cast is intermittently molded to the contours
of the foot from the back of the heel through the arch region, in
the region of the metatarsals, around them and even to the toes. Pressure
is expressed in terms of force or pounds over area per square inch.
Therefore, if the weight-bearing area is enlarged the pressure per
unit of weight-bearing area diminishes. In this way the pressure which
has been concentrated on the bony prominence is distributed over the
entire plantar aspect of the foot, allowing reversal of the mechanism
that caused the ulcer to occur.
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For the Charcot foot, the total contact cast is used in two ways.
In the initial treatment of the Charcot foot when the breakdown is
occurring and the foot is quite swollen and reactive, the cast is
applied to control the movement of the foot and support its contours.
In this instance the patient is often asked not to bear weight on
the foot. In the second instance when the foot has already become
deformed and ulceration has occurred, the principle using the cast
is the same as described for the foot that has become deformed due
to paralysis of the small muscles. |
The total contact cast, when used for the just described applications,
is a very effective treatment. A prerequisite is that the foot must
have an adequate blood supply, and therefore, the foot must be monitored
quite carefully. The cast must be applied by someone who has experience
with the applications and use of this cast. The cast must be changed
at regular, short intervals of a week or two. The reason for this
caution is that the diabetic who has insensitive feet runs the risk
of having other sores or areas of irritation occur under the cast.
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The cast is applied in a different fashion that normal casts. It is
common to have the patient lie on his stomach on the casting table
with the leg pointed straight up. The ankle should be bent to a neutral
position if possible. In this way the doctor applying the cast has
access to the sole of the foot which is the all-important area. A
thin dressing is applied over the ulcer. A thin layer of stockinette
is applied and protective cast padding applied between the toes. Cast
padding is applied very thinly up the limb and then secondary foam
padding is applied over the toes at the bony prominences on the inner
and outer side of the ankle and often times of the sides of the cast
and the front of the shin. Once this has been accomplished, the plaster
undercoat is applied very carefully and smoothly to the foot and leg,
completely encasing the toes and going up the leg. The sole of the
cast is quite carefully and intimately molded to the contours of the
sole of the foot. These valleys are then filled in with plaster of
Paris or other material so that the sole of the cast is flat. The
cast is often at this point reinforced by fiberglass and a special
curved or rocker-bottom sole is applied to relieve the stresses of
walking if the patient is to be allowed to bear weight. |
These casts are then changed weekly or every other week depending
on the physician, his experience with each individual patient, and
the amount of swelling in the leg. Casting is continued until the
ulcer is healed, and the foot is ready for appropriate shoewear and
orthotics. In the case of the Charcot process, casting is continued
until the patient's fractures heal and the foot no longer needs a
cast for protection. Because of the prolonged need for immobilization,
the physician typically may convert the treatment to a removable walking
boot. The total contact casting technique is an effective treatment
for ulcers and Charcot foot problems. |
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