Arterial ulcer

Question 1

Define arterial ulcer

Answer 1

A localised area of damage and breakdown of skin due to inadequate arterial blood supply.

Usually seen on the feet of patients with severe atheromatous narrowing of the arteries supplying the legs

Question 2

Explain the aetiology/risk factors of arterial ulcers

Answer 2

The ulcers are caused by a lack of blood flow to the capillary beds of the lower extremities

Risk Factor;
Coronary heart disease 
History of stroke or TIA  
Diabetes mellitus  
Peripheral arterial disease (e.g. intermittent claudication) 
Obesity and immobility

Question 3

Summarise the epidemiology of arterial ulcer

Answer 3

22% of leg ulcers

Prevalence increases with age and obesity

Question 4

What are the presenting symptoms of arterial ulcers?

Answer 4

Ulcer is often DISTAL - at the dorsum of the foot or between the toes

Punched-out appearance

Often elliptical with clearly defined edges

The ulcer base contains grey, granulation tissue

NIGHT PAIN - hallmark of arterial ulcers

Pain is worse when supine (because arterial blood flow is further reduced when supine)

Pain is relieved by dangling the affected leg off the end of the bed

Question 5

Recognise the signs of arterial ulcers on physical examination

Answer 5

Night pain

Punched-out appearance

Hairlessness

Pale skin

Absent pulses

Nail dystrophy

Wasting of calf muscles

Question 6

Identify appropriate investigations for arterial ulcers

Answer 6

Duplex ultrasonography of lower limbs - assess patency of arteries and potential for revascularisation or bypass surgery

ABPI - ankle brachial pressure index.

Percutaneous angiography

ECG

Fasting serum lipids, fasting blood glucose and HbA1c (diabetes is a major risk factor)

FBC - anaemia can worsen the ischaemia

Question 7

What is the utility of Ankle brachial (systolic) pressure index?

Answer 7

Compared to the arm, lower blood pressure in the leg suggests blocked arteries due to peripheral artery disease

Question 8

What is the utility of duplex ultrasonography in arterial ulcers?

Answer 8

It visualises the vasculature in the legs, are they patent? direction of flow can also be determined to seeif blood supply is good.