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
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.
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
Associated signs of chronic venous hypertension?
- Venous flare
- Lipodermatosclerosis
- Atrophie blanche
- Varicose eczema
- Varicose veins
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
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.
Appearance of arterial ulcers?
Punched out painful 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’
Appearance of ulcer due to malignancy?
Rolled edges
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
This is a healing ulcer. What are the red spots?
Ulcers heal by granulation and re-epithelialisation. Red spots are granulation tissue (red as rich in capillaries)
Ulcer examination and treatment
