Ulcer Reference

1. What is the definition of ulcer?
ulcers are open sores on the skin surface or mucous membrane and ulceration is the death of an extensive network and is accompanied saprofit invasive germs. The existence of these bacteria cause ulcers saprofit smelling, diabetic ulcers is one of the clinical symptoms and course of the disease diabetes mellitus with peripheral neuropathy.

2. What is the definition of diabetic foot ulcers?
Diabetic foot ulcers (DFU) is a complication associated with morbidity caused by diabetes mellitus. Diabetic foot ulcers are serious complications associated with diabetes.

3. How physiological occurrence of diabetic foot ulcers?
Ulcers occur because of narrowed arteries and in addition there is also an excess of sugar in the network which is a very good medium for bacteria, ulcers occur in areas that often get the press out of or trauma to the sole of the foot ulcer usual round of more than 1 cm in diameter containing the mass horn fat tissue, pus, and crusting over.

4. How patofisiologis on diabetic foot problems?
three different processes play a role in diabetic foot problems:
1) caused by ischemia and mikroangiopati makroangiopati
2) neuropathy: sensory, motor, and autonomic
3) sepsis: tissue containing glucose saturated support bacterial growth.

5. What patofisiologis clinical picture of diabetic foot?
neuropathic picture
? sensory disturbance
? trophic skin changes
? plantar ulcer
? atropati degenerative (Charcot joints)
? often palpable pulsation
? sepsis (bacteria / fungi)
ischemia picture
? pain at rest
? painful ulcers around the depressed area
? history of intermittent claudication
? pulsation was not palpable
? sepsis (bacteria / fungi)

6. There are several grades on diabetic ulcers?
Grade diabetic ulcers are:
1). Grade 0: no injuries
2). Grade I: feel just until the skin surface
3). Grade II: skin damage to muscle and bone
4). Grade III: occurs abscess
5). Grade IV: gangrene in the foot, distal
6). Grade V: gangrene pad the entire foot and lower distal tungkak.

7. What is the definition of diabetes mellitus?
Diabetes mellitus is a metabolic abnormalities are found by the inability to oxidize carbohydrates, due to interference with the normal insulin mechanism, causing hyperglycemia, glikosuria, polyuria, thirst, hunger, body lean, and weakness.

8. What are the complications caused by diabetes mellitus?
Complications of diabetes mellitus are as follows (Mansjoer, 1999):
a. Acute Complications
1. Chronic hypoglycemia
2. Type I diabetic ketoacidosis for
3. Koma hiperosmolar nonketotik for Type II DM

b. Chronic Complications
1. Makroangiopati on large blood vessels, blood vessels, heart, peripheral blood vessels, and blood vessels of the brain
2. Mikroangiopati of small blood vessels of diabetic retinopathy and diabetic nephropathy
3. Diabetic neuropathy
4. Vulnerable to infections such as tuberculosis and urinary tract infections
5. Diabetic ulcer

9. What kind of amputation that can be performed on diabetic foot?
digital, ray, lisfranc / transmetatarsal, Syme.

10. What is the purpose for which treatment and care ulcer / its management?
Ulcer care and treatment undertaken with the aim at the underlying disease and against his own ulkusnya namely:
? Try to medication and treatment directed against the diseases of
causal disease underlying the DM.
? Business ulkusnya directed against, among others, with antibiotics or
chemotherapy. Giving mengompreskan ulcer wound with a solution
chloride solution or a mild antiseptic. For example rivanol and potassium solution
permanganate 1: 500 mg and the closure of the ulcer with sterile gauze.
Orthopedic appliances which mechanically that could flatten the body pressure
of leg injuries. Am-amputated may be required for cases of DM

11. If the treatment of diabetic foot less intensive / less careful, it will lead?
diabetic ketoacidosis

12. Prevention (of things to do)?
Make:
? Wash and dry feet carefully every day
? Check your feet every day
? Perform regular maintenance toenails
? Use an antifungal powder

13. Prevention (things that should not have done)?
don’ts:
? Walking barefoot
? Using a shoe that is too narrow
? Using a hot water bottle
? underestimate any trauma to the legs

14. Therapeutic what can be done in the case of diabetic foot?
Selusitis
? Remove all sources of sepsis
? intravenous antibiotics immediately
Nadi (can not palpable)
? The main arterial inflow problems in the conventional treated as POVD
Chronic osteomyelitis (usually secondary to the ulcer)
? Antibiotics
? Amputation
Ulcers on pressure points
? Control of sepsis
? Clean up dead tissue
? Consider local amputation
Paronikia infection
? Drainage pussy
? Consider nail excision
? podiatry
Joint disorders
? Shoes / footwear that fits
? bearing sengan Footwear

15. What kind of clinical picture in the case of diabetic foot?
Diabetic gangrene gangrene due mikroangiopatik also called hot because although necrosis, akral area was red and feel warm by inflammation, and usually palpable in the distal arterial pulsation. There is usually on the palms of diabetic foot ulcers.

Makroangiopati process causes blockage of blood vessels, whereas in acute pulmonary embolism will provide clinical symptoms 5 P, namely:
a. Pain (pain).
b. Paleness (pallor).
c. Paresthesia (parestesia and tingling).
d. Pulselessness (missing pulse).
e. Paralysis (paralysis).

If there is chronic obstruction, will arise from the pattern of clinical features according to Fontaine, that is 4:
a. Stage I: asymptomatic or atypical symptoms (tingling or geringgingan).
b. Stage II; happens intermittent claudication.
c. Stage III; resulting pain at rest.
d. Stage IV; form of manifestation of tissue damage because anoksia (ulcers).

16. What are the classification of diabetic foot?
Classification:
According to the severity of the lesions, diabetic foot disorders are divided into six degrees according to Wagner, that is;

Diabetic Foot Classification System, Wagner.
Degree of lesion
0 skin is intact, there is foot deformity due to neuropathy
A superficial ulcers
2 Ulcers deeper
3 ulcers in along with the possibility of cellulitis and abscess or osteomyelitis
Fourth finger gangrene
5 foot gangrene

Classification of diabetic foot lesions can also be based on the extent of its wounds and ischemic regions is modified by Brodsky of classification of diabetic foot according to Wagner.

Diabetic Foot Classification System, modifications Brodsky.
The depth of the wound Definition
0 Feet-risk, without ulceration
A superficial ulceration, without infection
2 Ulceration of the till of the tendon
Three broad ulceration / abscess

17. Type Size injuries seen from ischaemia regions, among others:
A Without ischaemia
B ischaemia without gangrene
C Partial gangrene
D Complete foot gangrenen

18. What rules of prevention can be done?
Prevention of diabetic foot rule, namely:
a. Each of infection, although small is an important problem that demands full attention.
b. Feet should be cleaned thoroughly and dried with a dry towel every time the shower.
c. Feet should be inspected every day, including palms, can by using the mirror.
d. Feet should be protected from the cold.
e. Feet should be protected from the heat, sand stone or hot and fire.
f. Shoes should be wide enough and fit.
g. Recommended wearing socks at all times.
h. Socks should match and thoroughly worn without folds.
i. Footwear without handles, ribbon or rope between the fingers.
j. Cut nails straight.
k. Stop smoking.

19. What can we understand the prognosis of diabetic foot problems?
Prognosis:
Prognosis of patients with diabetic foot depends on your age because the older patients with diabetes mellitus, the easier it is to get serious problems in the feet and legs, long suffering from diabetes mellitus, severe infection, the degree of the quality of circulation, and the skills of medical or paramedical personnel

20. Handling of diabetic ulcers can be done in several levels, namely:
a) Level 0.
Handling includes educating the patient about specific and complementary footwear footwear is recommended. Shoes or sandals that are made specifically to reduce the pressure. If there are bones in the feet protruding or any deformity, usually can not be simply overcome by the use of artificial footwear generally require the cutting action of bone protruding (exostectomy) or correcting the deformity.
b) Level I.
Requiring debridement of necrotic tissue or tissue infectious, local treatment of wounds and the reduction of the load.

c) Level II.
Require debridement, appropriate antibiotics with culture results, the local treatment of wounds and expense reduction technique that is more meaningful.

d) Level III.
Debridement requires a network that has become gangrenous, amputation part, the more stringent immobilization and parenteral antibiotics according to culture.

e) Level IV.
At this stage usually requires action amputation amputation of part or all of the foot.

Reference:

Umami, Vidhia, Dr. 2007. Surgery at a Glance, Third Edition. New York: publisher
Union of Indonesian experts in the disease. 1996. Books Subjects Science Medicine. Third Edition. Sydney: New Style.
Dorland Pocket Medical Dictionary, Medical Book Publishers EGC, Jakarta, 1998. P. 309.
Noer, Prof.dr.H.M. Sjaifoellah. 2004. Endocrine and Metabolic Diseases Science, Medicine Science Textbook, Volume I. Jakarta: Balai Publisher FKUI. P. 571-705.

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