Arterial ulcer

Question 1

Define

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

What’s the aetiology?

Answer 2

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

Question 3

What are the risk factors?

Answer 3

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

Question 4

What are the presenting symptoms?

Answer 4

• 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
o Pain is worse when supine (because arterial blood flow is further reduced when supine)
o Pain is relieved by dangling the affected leg off the end of the bed

Question 5

What are the signs?

Answer 5

• Night pain
• Punched-out appearance
• Hairlessness
• Pale skin
• Absent pulses
• Nail dystrophy
• Wasting of calf muscles

Question 6

What are the appropriate investigations?

Answer 6

• Duplex ultrasonography of lower limbs - assess patency of arteries and potential for revascularisation or bypass surgery
• ABPI
• Percutaneous angiography
• ECG
• Fasting serum lipids, fasting blood glucose and HbA1c (diabetes is a major risk factor)
• FBC - anaemia can worsen the ischaemia