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So ... what bought you here today > 28. Leg Ulcer > Flashcards

28. Leg Ulcer Flashcards

1
Q

List a differential diagnosis of leg ulcers.

A 
Venous ulcers 
Mixed ulcers 
Arterial ulcers 
Neuropathic ulcers 
Pressure ulcers 
Lymphoedema ulcers 
Traumatic ulcers
Vasculitic ulcers 
Marjolin’s ulcers
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2
Q

What type are the majority of leg ulcers?

A

Venous ulcers – 70%

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3
Q

List two key features of the ulcer history.

A

Is the ulcer painful?

How long has the ulcer been there?

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4
Q

What is a Marjolin’s ulcer?

A

A squamous cell carcinoma arising from chronically inflamed tissue

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5
Q

How does the pain differ in venous, arterial, neuropathic and pressure ulcers?

A

Venous Ulcers

  • Not particularly painful
  • Pain is relieved when the leg is elevated (because pain/ulcer is caused by venous stasis)

Arterial Ulcers

  • Quite painful
  • Pain is worse when the leg is elevated (because pain is due to ischaemia)

Neuropathic Ulcers
- NO pain

Pressure Ulcers

  • Exquisitely tender
  • Not necessarily painful
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6
Q

How does the time of presentation of ulcers differ in venous, arterial, neuropathic, pressure and marjolin ulcers

A

Venous Ulcers
Present late because they aren’t that painful
Tend to have long, recurring history
Arterial Ulcers
Present early because they are painful
Often present secondary to trivial trauma
Neuropathic Ulcers
Present late because they are not painful
Pressure Ulcers
Can develop surprisingly fast (especially in hospital because of bed rest)
Marjolin Ulcers
Long-history of an ulcer/chronic skin inflammation that has suddenly changed

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7
Q

List some key associated features of venous ulcers

A

Varicose veins
Skin changes: haemosiderin deposition, stasis dermatitis, lipodermatosclerosis
Ankle oedema

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8
Q

List some key associated features of arterial ulcers

A

Peripheral vascular disease (e.g. claudication, night pain, rest pain)
Coronary artery disease (e.g. angina, SOBOE)
Cerebrovascular disease (e.g. stroke, TIA)

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9
Q

List some key associated features of neuropathic ulcers

A

Sensory loss
Unstable gait
Infected ulcers (mainly in diabetics)

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10
Q

List risk factors for venous ulcers

A 
Presence of varicose veins 
Immobility
Malnourishment 
Recurrent DVTs 
Pelvic mass compressing iliac veins 
AV malformations 
Major joint replacement (carries high subclinical DVT risk)
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11
Q

List risk factors for arterial ulcers

A

Atherosclerosis risk factors: hypertension, diabetes, smoking, hypercholesterolaemia etc.

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12
Q

List risk factors for neuropathic ulcers

A

Diabetes mellitus

Alcohol abuse

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13
Q

List risk factors for pressure ulcers

A

Long-term bed rest

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14
Q

Describe the common sites of venous ulcers

A

Gaiter area of the legs (mainly above the medial malleolus)

This is where venous pressure is highest

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15
Q

Describe the common sites of arterial ulcers

A

Distal areas (e.g. between the toes) and frequently compressed areas (e.g. ball of foot)

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16
Q

Describe the common sites of neuropathic ulcers

A

Pressure areas (e.g. ball of foot) – because it is subject to repetitive trauma

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17
Q

Describe the common sites of pressure ulcers

A

Bony prominences that experience constant pressure (e.g. heel)

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18
Q

Describe the characteristics of venous ulcers

A

Shallow
Wet
Irregular borders that look white and fragile

19
Q

arterial ulcers

A

Deep
Dry
Punched-out appearance
Often elliptical

20
Q

Describe the characteristics of neuropathic ulcers

A

Thick, keratinized raised edges surrounding the ulcer

21
Q

Which diseases are associated with pyoderma gangrenosum?

A 
Inflammatory bowel disease 
Blood dyscrasias (e.g. multiple myeloma)
22
Q

Describe the typical appearance of pyoderma gangrenosum.

A

An ulcer with a characteristic purple halo around it

23
Q

Venous ulcers can scar leading to white patches of scarred skin. What is this feature called?

A

Atrophie blanche

24
Q

What is the term used to describe severe lipodermatosclerosis?

A

Inverted champagne bottle sign

25
Q

Describe some features of the affected limb in a patient with arterial ulcers.

A 
Cold 
Pale
Absent/weak pulses 
Delayed capillary refill time 
Atrophic skin changes (dry, shiny, hairless)
26
Q

What is Buerger’s test? Describe how it is performed and what a positive result indicates.

A

Whilst the patient is supine, raise the leg up until it goes pale
NOTE: in normal people, the leg should remain pink even at 90 degrees
The angle at which it goes pale is ‘Buerger’s angle’
Then the leg is put back down
With positive Buerger’s sign – the leg will slowly turn pink but then it will go red (this is due to reactive hyperaemia)

27
Q

Describe some features of the affected limb in a patient with neuropathic ulcers.

A 
Loss of sensation (gloves and stockings distribution)
Foot deformities (e.g. Charcot foot)
28
Q

Why would you check FBC in a patient with ulcers?

A

Anaemia could worsen the ischaemia that causes ulcers

29
Q

List some other investigations that you would use in a patient with a suspected venous ulcer.

A 
Fasting lipids 
Capillary glucose 
Urinalysis 
Venous duplex ultrasound – good for assessing saphenofemoral competence
ABPI
30
Q

Why is it important to calculate the ankle-brachial pressure index (ABPI) before treating an ulcer?

A

This allows assessment of arterial disease

ABPI < 0.8 – do NOT apply pressure bandage because it will worsen the ischaemia

31
Q

Which ulcers may require a biopsy?

A

Marjolin’s ulcer

32
Q

Outline the management of venous ulcers.

A 
Adequate nutrition
Leg elevation 
Compression bandages
Elastic stockings 
Varicose vein surgery
33
Q

Define critical limb ischaemia.

A

Severe obstruction of the arteries which markedly reduces blood flow to the extremities and has progressed to the point of causing severe pain, ulcers or gangrene. These patients will have rest pain.

34
Q

List some investigations for suspected arterial ulcers.

A 
Duplex ultrasonography – assess arterial patency
Percutaneous angiography 
ECG 
Fasting lipids, glucose, HbA1c
FBC
35
Q

Outline the management of arterial ulcers.

A

Dress the ulcer to prevent infection
Analgesia
Antibiotics (if signs of infection)

36
Q

List some surgical options for treating arterial ulcers.

A

Angioplasty
Bypass surgery
Amputation

37
Q

What causes acute limb ischaemia?

A

A sudden lack of blood flow to a limb

38
Q

What are the signs of acute limb ischaemia? 6 Ps of acute limb ischaemia

A 
Pale 
Pulseless 
Painful
Paralysis 
Paraesthesia
Perishingly cold
39
Q

List some possible interventions for acute limb ischaemia.

A 
Embolectomy 
Percutaneous thrombolysis 
Revascularisation angioplasty
Bypass surgery
Amputation
40
Q

Outline the treatment of neuropathic ulcers.

A

Foot care
Manage diabetes
Debridement of necrotic tissue
Treat infections

41
Q

What is a major complication of neuropathic ulcers?

A

Osteomyelitis

42
Q

Outline the management of pressure ulcers.

A

Record the ulcer
Relieve the ulcer
Reduce further ulcers
Reassess ulcer

43
Q

List some surgical options for varicose veins.

A

Avulsion/phlebectomy
Stripping
Injection sclerotherapy
Radiofrequency ablation

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