Nerve Disease and Amputations
 About 60-70 percent of people with diabetes have mild to severe forms of diabetic nerve damage, which, in severe forms can lead to lower limb amputations. In fact, diabetes is the most frequent cause of non-traumatic lower limb amputations.  Each year, more than 56,000 amputations are performed among people with diabetes.
Diabetes is the seventh leading cause of death (sixth-leading cause of death by disease) in the United States. Based on death certificate data, diabetes contributed to more than 187,000 deaths in 1995.
There are 15.7 million people or 5.9% of the population in the United States who have diabetes. While an estimated 10.3 million have been diagnosed, unfortunately, 5.4 million people are not aware that they have the disease. Each day approximately 2,200 people are diagnosed with diabetes. About 798,000 people will be diagnosed this year.

New Zealand statistics
Total estimated cost in NZ - $70 million
Total estimated hospital costs $11 million
Mean cost of amputation $26 000
Mean cost of hospitalisation for ulcer - $12500

 Complications are circulation problems and nerve impairment which causes a problem in a foot with deformity

 Circulation

• There is an acceleration of  large and small blood vessel disease in diabetics
• Atherosclerotic process( fatty plaques in arteries) is more common in the diabetic population
• Below knee is most commonly affected.

• absence of pulses blanching of foot on elevation
• cold  feet
• rest pain, night pain eased by hanging foot out of bed
• thinning of fatty tissue
• loss hair on foot and toes
• shiny skin
• thickened nails with fungal infection
• blue toes
• red looking foot
• ulcers that will not heal
• infection resistance to  treatment

• It causes weakness in small muscles of foot causing toes to claw, foot drop
• Lack of sweating which changes pH decreases defenses against bacteria and causes dry skin which is vulnerable to cracking
• Pain, tingling , burning, numbness in feet eg across toes and even up to calves
• Loss of tendons reflexes, vibration sense
• Callus, ulcers
• Can’t tell when there is a change in temperature, so blood supply may be shut off too long, or not be able to feel how hot the bath is.
• No pain when pressure from shoe, nails  leads to callous, infection and ulcers
• thinning of bones  vulnerable to fracture and can cause collapse of arch area. This is called charcots joints
• Even if a person has nerve or circulation impairment they may be okay if the foot stay uninjured
•  So the thing that can set ulcers, infection off is the presence of  physical trauma eg drawing pin. Prolonged pressure  against one area of the foot eg bunion stops the blood supply to those areas and causes the tissue to break down. It doesn’t take much pressure to do this if there is reduced blood supply already present. Happens also commonly with new pair of shoes and prolonged pressure on the heel when  in bed a lot.
• Repetitive pressure causing corns and callus as in walking. Becomes more prevalent when the toes claw, bone under and sideof the foot deform

• Diabetes may affect the nerve so that pain signals arising in the foot do not reach the brain.  The diabetic must use other senses especially eyes and hands to detect earliest signs of injury
• Daily inspect feet.  Use mirror, look for  red redness sores, cracks
• Never  walk barefooted .  Avoid casual footwear or sandals that leave toes exposed.
• Wear thick socks eg Thorlos socks
• Shoes -  buy leather shoes suede
• extra depth shoe with a quarter inch removable inlay that can be modified or replaced
• or new  balance shoes, custom molded shoes,  custom molded orthotics, rocker soles
• Wear new shoes no than two hours.  Then inspect feet for pressure, blisters, cracks
• Feel inside shoes for foreign material and roughness
•   Wash feet daily in plain soap.  Dry gently  especially between toes
•  Don’t buy shoes to tight and depend on them stretch
• Don’t wear restrictive clothing e.g. leg garters or cross legs
• Toenails -  trim straight across
• Callus—use pumice or emery board—no chemical removers
• No hot water bottles placed against feet, bath water  check temperature with elbow.  Don’t walk on hot surfaces
• Use soft insoles e.g. plastazote
• Moisturize skin