5: Lower Limb Ulcers Flashcards
define an ulcer
abnormal breaks in the skin or mucous membranes
what is a venous ulcer and describe its appearance
caused by venous insufficiency
- shallow with irregular borders and a granulating base
- characteristically located over the medial malleolus
- most common type of leg ulcer
- prone to infection –> associated cellulitis
what is the pathophysiology of venous ulcers
- valvular incompetence or venous outflow obstruction –> impaired venous return
- resultant v. hypertension causes ‘trapping’ of WBCs in capillaries and formation of fibrin cuff around vessel which hinders o2 transportation
- WBCs become activated w release of inflamm mediators –> resultant tissue injury, poor healing and necrosis
what are risk factors for developing a venous ulcer
- increasing age
- pre-exisitng venous incompetence
- pregnancy
- obesity/physical inactivity
- severe leg injury or trauma
what are the clinical features of venous ulcers
syptoms/examination findings
- painful esp at end of day
- often found in gaiter region of legs
- ± aching, itching, bursting sensation
- O/E: varicose veins + ankle/leg oedema
- varicose veins/thrombophlebitis
- haemosiderin skin staining
how is diagnosis of venous ulcer reached
- largely clinical with the underlying venous insufficiency confirmed by Duplex USS
- ABPI: assess for arterial component to ulcer
- swab cultures: if suspected infection + consider a thrombophilia and vasculitis screening in young pt (esp if prominent FHx)
what is conservative management for venous ulcers
- leg elevation and increased exercise to promotoe calf muscle pump to aid with venous return
- lifestyle changes incl weight reduction and improved nutrition
- mainstay: multicomponent compression bandaging changed once or twice a week
- ABPI must be > 0.6 before applying any bandaging + appropriate dressings and emollients
what are 2 common locations of venous incompetence
sapheno-femoral/ sapheno-popliteal junction
what is an arterial ulcer
- describe its pathophysiology and appearance
caused by reduction in arterial blood flow –> decreased perfusion of tissues and subsequent poor healing
- small deep lesions with well-defined borders and necrotic base
where do arterial ulcers commonly occur
distally at sites of trauma and in pressure areas e.g. heel
what are the main risk factors of arterial ulcers
those of PAD: smoking, DM, HTN, hyperlipidaemia
how might an arterial ulcer present
- preceding history of intermittent claudication or critical limb ischaemia
- painful and develops over a long period of time w little to no healing (so little granulation)
- ± cold limbs, thickened nails, necrotic toes and hair loss
- O/E: cold w absent pulses but sensation maintained
how is an arterial ulcer investigated
- ABPI: >0.9 = normal; 0.9-0.8 = mild; 0.8-0.5 = moderate; <0.5 = severe
- duplex
- CTA/MRA
what is the NICE guidance for any patient with critical limb ischaemia
urgent referral for a vascular review
what is the conservative management of arterial ulcers
lifestyle changes e.g. smoking cessation, weight loss, exercise
how do neuropathic ulcers present
- hx of peripheral neuropathy or PVD
- burning/tingling in legs
- single nerve involvement (mononeuritis multiplex e.g. CN III or median nerve
- amotrophic neuropathy (painful wasting of prox quadriceps)
- O/E: variable in size and depth ‘punched out’ appearance
