Chronic Leg Ulcer Flashcards
What is an ulcer?
A local defect, or excavation of tissue that is produced by sloughing of inflammatory necrotic tissue
What is a skin ulcer?
A loss of area of epidermis and dermis to produce a defect, even down to fat, muscle, tendons and bone
What are the causes of leg ulcers?
Vascular - 90% - Venous 70% - Arterial 10% - Mixed 10% Other - 10%
What is a chronic venous leg ulcer defined as?
An open lesion between the knee and the ankle joint that remains unhealed for at least four weeks and occurs in the presence of venous disease.
Who do venous leg ulcers most commonly affect?
Middle aged to elderly women
What are the risk factors for venous leg ulcers?
- Valvular incompetence (1ary or 2ary) - Previous damage to venous system (DVT, hypertension, peripheral oedema) - Obesity, immobility
What is 1ary valvular incompetence?
For example, due to laxity of the vein wall or valve cusps
What is 2ary valvular incompetence?
For example when valves are damaged as a result of deep vein thrombosis.
Why is obesity/immobility a risk factor for venous leg ulcers?
Poor muscle contraction –> venous pooling and hypertension
Patient history for venous leg ulcers:
- Varicose veins - History of leg swelling of any cause - History of DVT/PE - Sitting or standing for long periods - End of day throbbing and aching in the calf muscles - High blood pressure - Multiple pregnancies - Previous surgery e.g. knee replacement - Fractures or injuries - Obesity - Increasing age and immobility
How can multiple pregnancies increase risk of leg ulcers?
Increased circulating volume
How can previous surgeries, fractures or injuries increase risk of leg ulcers?
Damage to veins, immobility
What causes venous leg ulcers?
If there’s a problem with the circulation of blood in your leg veins, pressure inside the veins increases. This constant high pressure can gradually damage the tiny blood vessels in your skin and make it fragile. As a result, your skin can easily break and form an ulcer after a knock or scratch.
Where do most venous leg ulcers occur?
Medial gaiter area - area extending from just above the ankle to below the knee
Are venous ulcers more or less painful than arterial ulcers?
Generally less painful
Appearance of venous leg ulcers
Superficial, sloughy with ill defined borders
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There are often associated sings of chronic venous hypertension alongside venous leg ulcer. What is chronic venous hypertension?
High pressure in the veins of the legs.
What are varicose veins?
Varicose veins are usually caused by weak vein walls and valves. Sometimes the walls of the veins become stretched and lose their elasticity, causing the valves to weaken.
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Patients with leg ulceration are at risk of developing cellulitis. What is bilateral cellulitis?
Cellulitis is a bacterial infection that spreads across the dermis and subcutaneous tissues of the skin
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Associated signs of chronic venous hypertension?
- Venous flare
- Lipodermatosclerosis
- Atrophie blanche
- Varicose eczema
- Varicose veins
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What is lipodermatosclerosis?
An inflammatory skin condition resulting from underlying venous insufficiency. The resulting venous hypertension causes an increase of leukocytes within the veins, which then migrate into surrounding tissue.
The leukocytes become activated, attracting and releasing proinflammatory cells and cytokines, inducing a chronic inflammatory state. Increased collagen production leads to the fibrosis of subcutaneous fat. Commonly misdiagnosed as cellulitis.
What are arterial ulcers caused by?
Associated with peripheral vascular disease i.e. develop as the result of damage to the arteries due to lack of blood flow to tissue
An ulcer due to inadequate blood supply to the affected area (ischaemia).
Difference in cause of arterial and venous ulcers?
Arterial ulcers develop as the result of damage to the arteries due to lack of blood flow to tissue. Venous ulcers develop from damage to the veins caused by an insufficient return of blood back to the heart.
How can plaque build up lead to an arterial ulcer?
- Plaque build up in arteries that carry blood to lower limbs
- Leads to inflammatory cascade
- Plaque hardens and narrows the arteries
- This limits flow of O2 rich blood to legs etc
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What is plaque made up of?
Fat, cholesterol, calcium, firbous tissue and other substances in the blood
What are the risk factors for arterial ulcers?
Anything that can cause CVS/peripheral vascular disease:
- Diabetes
- Smoking
- High blood lipids
- High blood pressure
- History of ischaemic heart disease, cerebrovascular disease or peripheral vascular disease
- Renal failure
- Obesity
- Rheumatoid arthritis
- Clotting and circulation disorders
What history do you need to ask patient about in arterial ulcers?
- Intermittent claudication
- Rest pain or paraesthesia
- Pain at ulcer site
- Other symptoms of vascular disease e.g. angina
What is intermittent claudication?
A symptom that describes muscle pain on mild exertion (ache, cramp, numbness or sense of fatigue), classically in the calf muscle, which occurs during exercise, such as walking, and is relieved by a short period of rest.
What is paraesthesia?
An abnormal sensation, typically tingling or pricking (‘pins and needles’), caused chiefly by pressure on or damage to peripheral nerves.
Appearance of arterial ulcers?
Punched out painful ulcer
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Clinical finding during examination of arterial ulcer?
- Lower leg/foot
- Loss of hair appendages
- Dry skin
- Cool peripheries
- Pale or cyanotic or pre-gangrenous toes
- Reduction in proximal and/or peripheral pulses (ABPI)
- 5 P’s of PVD
What are the 5 P’s of PVD?
Signs of peripheral vascular disease:
- pain
- paralysis
- pallor
- paresthesia
- pulselessness.
What are neuropathic ulcers?
A neuropathic ulcer is one that occurs as a result of peripheral neuropathy. In peripheral neuropathy, there is a loss of protective sensation which leads to repetitive stress and unnoticed injuries forming, resulting in painless ulcers forming on the pressure points on the limb.
What are the causes of neuropathic ulcers?
Loss of sensation due to distal polyneuropathy (motor/sensory/autonomic)
What is polyneuropathy?
a condition in which a person’s peripheral nerves are damaged.
Are neuropathic ulcers painful?
Often painless due to neuropathy (often may not even be aware)
What is diabetic neuropathy?
Diabetic neuropathy is a type of nerve damage that can occur if you have diabetes. High blood sugar (glucose) can injure nerves throughout your body. Diabetic neuropathy most often damages nerves in your legs and feet.
Causes of polyneuropathy?
- Diabetes
- Alcohol
- B1/B12 deficiency
- Charcot Marie Tooth
What is charcot marie tooth?
a group of inherited conditions that damage the peripheral nerves.
An initial pustule is a rarer cause of an ulcer. What is a pustule?
A small blister or pimple on the skin containing pus. This can rapidly break down into a very painful rapidly spreading ulcer.
Colour and margins of a pustule ulcer?
Base of the ulcer: dark red or dusky in colour
Margins: overhanging (undermined) and purple/bluish ‘violaceous borders’
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What is Pyoderma Gangrenosum?
- A rare, inflammatory skin disease where painful pustules or nodules become ulcers that progressively grow.
- Inflammatory ulcer - no cause identified
- One of a number of ‘neutrophilic dermatoses’
What are neutrophilic dermatoses?
skin conditions characterised by dense infiltration of inflammatory cells (neutrophils) in the affected tissue.
What conditions is pyoderma gangrenosum associated with?
- Inflammatory bowel disease – Crohns, UC
- Rheumatoid arthritis
- Monoclonal gammopathy
What are the 3 main types of skin cancer?
- Basal cell carcinoma
- Squamous cell carcinoma
- Melanoma
In regards to ulceration due to malignancy, which skin cancers are most likely to be involved?
BCC or SCC
Appearance of ulcer due to malignancy?
Rolled edges
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What type of skin cancer does a long-standing wound increase your chances of?
SCC
Biopsy !!
What are the 2 types of wound healing?
Healing by first intention and healing by second intention
What is healing by first intention? Describe the process
Healing by primary intention occurs in wounds with dermal edges that are close together (e.g a scalpel incision).
- Clean cut wounds e.g. lacerations, surgical incision
- Minimal tissue loss
- Incision
- Exudation of fibrinogen
- Weak fibrin join
- Epidermal regrowth and collagen synthesis
- Strong collagen join
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What is the end result of healing by first intention?
The end result of healing by primary intention is (in most cases) a complete return to function, with minimal scarring and loss of skin appendages.
What is healing by second intention?
- Healing by secondary intention occurs when the sides of the wound are not opposed, therefore healing must occur from the bottom of the wound upwards.
- Wounds with tissue loss or wounds with margins not apposed
- E.g. ulcer
This is a healing ulcer. What are the red spots?
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Ulcers heal by granulation and re-epithelialisation. Red spots are granulation tissue (red as rich in capillaries)
Healing of ulcer by secondary intention process:
- Ulcer defect created –> a large fibrin mesh forms, which fills the wound
- Inflammation –> an inflammatory response acts to remove any cell debris and pathogens present (phagocytosis)
- Granulation tissue laid at bottom of ulcer to fill in defects and repair specialised tissues lost
- Organisation –> fibroblasts produce collagen and a scar is formed
- Over scar is re-epithelisation (epithelia grows back)
- Contraction of scar due to myofibroblasts
Do ulcers heal by first or second intention?
Second intention
Why is laying down granulation tissue important?
the epithelia can only proliferate and regenerate once granulation tissue fills the wound to the level of the original epithelium; once the granulation tissue reaches this level, the epithelia can completely cover the wound
Management of an ulcer?
- Treat the underlying cause
- Treat the ulcer
- Treat any associated infection
What do venous ulcers require for healing?
Compression (e.g. compression stocking, bandage)
Why do venous ulcers require compression?
Provides pressure to lower leg to help remove pooling of blood in venous system back up towards heart
How can you assess whether a patient is suitable for compression?
Ankle brachial pressure index (ABPI)
What is an ABPI?
A non-invasive method of assessing peripheral arterial perfusion in the lower limbs.
What is the problem with compression if the patient has arterial disease?
Compression can be harmful by leaving to further tissue ischaemia and necrosis
What are the values for ABPI?
–<0.5 significant arterial disease
–0.5-0.9 suggest claudication
–>1.0 non significant arterial disease
What are compression stocking/bandages?
NOT the same as standard bandages
Expert nurses and correct technique is critical and evidence based
What is Pentoxifylline used to treat? How does it work?
Pentoxifylline is used to improve blood flow in patients with circulation problems to reduce aching, cramping, and tiredness in the hands and feet. It works by decreasing the thickness (viscosity) of blood.
- Liscensed for venous leg ulcers
- Increases microvascular blood flow
- Enhances oxygenation of ischaemic tissue
What is Pentoxifylline?
A methylxanthine derivative and nonselective inhibitor of the cyclic nucleotide phosphodiesterases that increase the rate of breakdown of cAMP and cGMP.
What is the potential side effect of Pentoxifylline?
Hypotension
Other investigations for leg ulcers?
- Diabetes screening
- Vasculitis screen
- X-ray underlying bone
- May need bonescan or MRI if suspect chronic osteomyelitis underlying ulcer
- Venous duplex U/S
- Arteriography
- Biopsy
- Patch Testing
- Swab – only swab if clinically appears infected
Ulcer examination and treatment
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General advice to patients with leg ulcers?
- Avoid trauma to lower legs
- Stop smoking
- Moderate regular exercise
- Avoid obesity
- Avoid sleeping in chair
- Elevate legs
- Treat lower limb oedema & prevent chronic venous hypertension (supportive hosiery)
- Analgesia