Arterial & Venous Ulcers

Question 1

Arterial ulcers

Answer 1

• also known as ischaemic ulcers
• wounds that occur due to inadequate blood flow through arteries
• most common on lower extremities

Question 2

Main causes of arterial ulcers

Answer 2

Systemic diseases:
- peripheral artery disease
- diabetes mellitus
- rheumatoid arthritis

Lifestyle factors:
- tobacco use
- poor nutrition

Physical conditions:
- older age
- obesity
- immobility

Basically things causing poor blood flow to lower limbs

Question 3

Pathophysiology of arterial ulcers

Answer 3

Haemodynamics:
- obstructed blood flow (occlusion or stenosis in artery)
- decreased perfusion pressure (increased vasc. resistance)
- partially restored perfusion, chronic ischaemia

Endothelial dysfunction:
- endothelial cells have reduced blood flow -> promotes thrombosis and inflammation
- further contributes to thrombus formation

TIssue hypoxia:
- persistent low oxygen
- induces apoptosis -> reduced skin integrity, formation skin ulcers

Question 4

Classifying arterial ulcers

Answer 4

By aetiology:
- atherosclerotic ulcer
- vasculitic ulcer
- thromboembolic ulcer

By clinical presentation:
- painful ulcer
- painless ulcer

Question 5

Clinical features of arterial ulcers: Pain, Location, Appearance

Answer 5

Pain:
- severe
- worse at night
- worse with leg elevation
- relieved by hanging over side of bed (dependent relief)
- may have claudication pain

Location:
- distal aspects of lower extremities e.g. toes or lateral malleoulus
- pulseless foot

Appearance:
- deep, punched-out
- well-defined borders
- round or oval
- pale or black necrotic base

Question 6

Investigating arterial ulcers

Answer 6

1. ankle brachial pressure index (< 0.9)
2. doppler ultrasound
3. magnetic resonance angiography (MRA)
4. tissue biopsy

Question 7

Differentials for arterial ulcers

Answer 7

• venous ulcers (gaiter region, oedema, hyperpigmentation)
• diabetic foot ulcers (pressure points of feet, deep

Question 8

Managing arterial ulcers

Answer 8

• revascularisation
• wound care
• pain management
• lifestyle modifications

Question 9

Complications of arterial ulcers

Answer 9

Local:
- infection
- gangrene
- limb amputation

Systemic:
- sepsis
- pain
- iatrogenic complications

Question 10

Venous ulcers

Answer 10

Chronic wounds that occur primarily in lower limb due to impaired venous return - pooling of blood
Results in increased venous pressure and subsequent skin breakdown.

Question 11

Aetiology of venous ulcers

Answer 11

• chronic venous insufficiency
• DVT
• obesity
• immobility
• advancing age
• history of leg injury

Question 12

Clinical features of venous ulcers

Answer 12

• gaiter area of leg (ankle to mid-calf), above medial malleolus
• irregular, shallow wounds
• granulating base, substantial exudate
• surrounding skin shows oedema, hyperpigmentation, lopodermatosclersis, atrophie blance
• can be painful (but much less than arterial)

Question 13

Lipodermatosclerosis

Answer 13

hardening and discolouration of skin
seen in chronic venous insufficiency

Question 14

Atrophie blanche

Answer 14

Small, white scars surrounded by dilated capillaries
seen in chronic venous insufficiency

Question 15

Investigating venous ulcers

Answer 15

ankle-brachial pressure index

Question 16

Managing venous ulcer

Answer 16

• compression therapy (improve venous return, reduce oedema)
• wound care (regular cleaning and dressing)
• analegesics for pain, antibiotics for infection