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Vascular Surgery > 2: Limb Ulceration and Gangrene > Flashcards

2: Limb Ulceration and Gangrene Flashcards

1
Q

Define an ulcer

A

Break in skin or mucosa

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2
Q

What is the most common type of ulcer

A

Venous

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3
Q

What % of ulcers are venous

A

80

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4
Q

What are the three types of ulcer

A

Venous
Arterial
Neuropathic

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5
Q

What are the risk factors for arterial ulcers

A 
Smoking 
HTN
DM
Age 
Obesity 
Physical inactivity 
FH
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6
Q

What are the risk factors for venous ulcers

A 
Venous insufficiency 
Severe leg trauma
Pregnancy
Obesity 
Age
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7
Q

What are risk factors for neuropathic ulcers

A

Vitamin B12 deficiency

Diabetes mellitus

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8
Q

How will venous ulcers present clinically

A

V- SIG:
(Venous):

Shallow
Irregular borders
Granulating borders

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9
Q

Where are venous ulcers most often found

A

Medial malleolus

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10
Q

Are venous ulcers painful

A

Yes - pain is often worse towards end of the day

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11
Q

Describe symptoms of venous ulcers

A

Symptoms often precede the ulcer and include itching and aching

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12
Q

Where are arterial ulcers found

A

Distal sites - often areas of trauma or pressure areas

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13
Q

How will arterial ulcers present clinically

A

Deep, Well-defined borders

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14
Q

Are arterial ulcers painful

A

Yes

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15
Q

Describe symptoms prior to arterial ulcers

A

History of intermittent claudication

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16
Q

Where are neuropathic ulcers located

A

Pressure areas

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17
Q

What co-morbidities may someone with neuropathic ulcers have

A

Diabetes

Peripheral vascular disease

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18
Q

Are neuropathic ulcers painful

A

No

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19
Q

How are venous ulcers diagnosed

A

clinically

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20
Q

If a venous ulcer is present what may be used to confirm diagnosis of venous insufficeincy

A

Duplex US

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21
Q

What are the two most common sites of venous insufficiency

A

Sapheno-femoral

Sapheno-popliteal

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22
Q

Why may ABPI be performed for venous ulcers

A

To check for arterial component

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23
Q

If you suspect an ulcer is infected what should be done

A

Swab and culture

24
Q

What is done to investigate an arterial ulcer

A

ABPI

Duplex US and CTA

25
Q

What is done to investigate a neuropathic ulcer

A

HbA1c
Vitamin B12
X-ray - for osteomyelitis
10g mononeurofilament test to investigate extent of neuropathy

26
Q

How are venous ulcers managed

A
  • Raise legs
  • Exercises to increase calf muscles and venous return
  • Multicomponent compression bandaging
27
Q

How long is multi compression venous bandaging kept on for

A

6m

28
Q

How often is multi compression venous bandaging changed

A

1W

29
Q

When can multi compression venous bandaging only be applied

A

If ABPI > 0.6

30
Q

If individual with venous ulcer has venous insufficiency how may it be managed

A

Surgical intervention

31
Q

If an individual has arterial ulcers how may they be managed

A
  • If critical limb ischaemia refer for urgent vascular review
  • control RF: weight loss, supervised exercise program, diabetes control, anti-HTN, statin, anti-coagulants
  • angioplasty or bypass
32
Q

how are neuropathic foot ulcers managed

A
  • refer to diabetic foot clinic
  • regular podiatry inputs
  • surgical debridement of necrotic tissue
33
Q

what is gangrene

A

type of tissue death due to lack of blood supply

34
Q

what are the four types of gangrene

A
  1. Wet
  2. Dry
  3. Gas
  4. Fournier’s
35
Q

explain wet gangrene

A

Occurs following tissue infection with staphylococcus or streptococcus. Infection causes inflammation resulting in ischaemia and gangrene. The infection causes release of discharge - hence why it is wet

36
Q

how will wet gangrene present clinically

A

Foul Smelling Discharge

37
Q

how is wet gangrene managed

A
  • IV antibiotics: benzylpenicllin + clindamycin
  • Debridement
  • May need amputation
38
Q

What causes dry gangrene

A

Ischaemia due to vascular compromise such as from peripheral arterial disease

39
Q

Explain appearance of dry gangrene

A

Presents as cold and black area - skin will then slough off

40
Q

How should dry gangrene be managed

A

treat as critical limb ishaemia

41
Q

what are the three features of gas gangrene

A
  • Sepsis
  • Gas (Crepitus)
  • Myonecrosis
42
Q

what causes gas gangrene

A

Clostridium pefringens infection - releases a-toxin

43
Q

how may wounds become infected with clostridium pefringens

A

Contact of wound with soil or faeces

44
Q

how will gas gangrene present clinically

A
  • Starts with pain
  • Then systemic involvement (eg. Fever)
  • Cellulitis followed by purple vesicles and bullae
  • Crepitus on palpation of joints
45
Q

what is necrotising fasciitis

A

infection that results in death/necrosis of subcutaneous tissue

46
Q

how can necrotising fasciitis be classified

A

depending on causative organism

47
Q

what is type 1 necrotising fascitis

A

caused by mix of aerobes and anaerobes

48
Q

what is type 2 necrotising fascitis

A

caused by streptococcus pyogenes

49
Q

how does necrotising fascitis present clinically

A
  • acute-onset

- painful erythematous lesion (cellulitis) with pain out-keeping with clinical features.

50
Q

how should necrotising fascitis be managed

A
  • urgent surgical debridement

- IV antibiotics

51
Q

what is fournier’s gangrene

A

necrotising fascitis of the perineum

52
Q

what can cause fourniers gangrene

A
  • Mix anaerobes and aerobes

- Streptococcus pyogenes

53
Q

how does Fournier’s gangrene present in early stages

A

Fever

Pain out of proportion to clinical findings

54
Q

as fournier’s gangrene progresses how may it present

A

Haemorrhagic bullae
Skin Necrosis
Crepitus
Septic shock

55
Q

how is fournier’s gangrene managed

A

Urgent surgical debridement
IV antibiotics
HDU transfer

56
Q

what can be used to deride necrotic tissue

A

larval (maggot) therapy, hydrogels, surgery

Vascular Surgery (6 decks)

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