A7- Lower limb ulceration

Question 1

What are the two main sites of ulcers?

Answer 1

Leg and foot

Question 2

Leg ulcers can be ___ or ____ or _____

Answer 2

Venous or arterial or mixed

Question 3

Foot ulcers can be _______ ______ ____ _____

Answer 3

Neuropathic/Arterial/Mixed/Others

Question 4

Tx for lower limb ulcerations?

Answer 4

Treatment is to reverse the aetiology

 Arterial- identify lesion and treat it

 Neuropathic- offload the ulcer

 Venous leg ulcer- compression ( exclude arterial) treat venous lesion

Question 5

Examples of - leg ulcer aetiology

Answer 5

 Claudication

 Arterial disease elsewhere

 DVT

 Varicose veins

 Inflammatory diseases

Question 6

Arterial assessment- components in Palpation

Answer 6

 Temperature - cool suggests poor circulation, compare sides

 Capillary refill - 3 seconds.

 Pulses

Question 7

Pulses for lower limb assessment

Answer 7

 Dorsalis pedis -dorsal surface of the foot, running lateral to the tendon of the first toe

 Posterior tibial artery pulse - posterior and inferior to the medial malleolus

 Popliteal artery pulse - behind the knee, typically done with both hands- slightly bent knee

 Femoral artery pulse - in the femoral triangle - halfway between the ASIS and pubic tubercle

Question 8

What is duplex

What is used for?

Answer 8

 Duplex = Doppler + Ultrasound

 Used for both arterial and venous disease

 Doppler gives flow information

 Ultrasound anatomical info

 Skilled user required

 Operator dependent

 Essentially risk free

 Widely available in hours

Question 9

CT Angio/MR Angio for lower limb ulceration s

WHat do you see

Answer 9

More detailed anatomical information

 Very good for iliac

 Poor for calf/pedal vessels

 CTA: Radiation/contrast risks

 Widely available in/out of hours

 MRA: skilled radigraphers/ long scan/cost

 Not usually widely available

Question 10

What is gold standard for lower limb catherisaition?

Answer 10

Catheter angiography

Question 11

Angioplasty versus bypass

Answer 11

 Bypass or endarterectomy is much more invasive

 Higher short–term risks

 Better long-term results ( Basil trial)

 Bypass long occlusions

 Specific locations- EIA/CFA/popliteal

Question 12

DM foot ulceration

pressure points?

Answer 12

 Neuropathic-Pressure points toes /MT heads

 Arterial- anywhere, but mainly heel/ pressure points

Question 13

what is Heel perfusion pressure

Answer 13

Heel pressure occurs when people are laying down and the back of the heel is in contact with the bed. The weight of the leg is passed through the back of the heel where there is minimal padding or resilience to pressure.

Question 14

Are Venous leg ulcers common or uncommon

Answer 14

common

Question 15

What do you do in a Venous leg ulcer assessment

Answer 15

Venous ( deep/superficial)/ arterial history

 Examination- site size, skin condition

 Pulses

 ABPI- use with caution

 Arterial assessment- duplex etc

 Venous assessment- textbook clinical tests hopelessly outdated- must have duplex (NICE)

Question 16

Venous leg ulcer treatment

Answer 16