KEY NOTES CHAPTER 6: LOWER LIMB - Leg ulcers

Question 0

What is the aetiology (cause) of leg ulcers?

Answer 0

VATIMAN

1. Venous disease
2. Arterial disease
3. Trauma - insect bites, trophic ulcers, self-inflicted, burns & frostbite, radiation.
4. Infection - bacterial, fungal, mycobacterial, syphilis.
5. Metabolic disorders - diabetes, necrobiosis lipoidica diabeticorum, pyoderma gangrenosum, porphyria, gout, calciphylaxis.
6. Autoimmune diseases - vasculitis, SLE, scleroderma (systemic sclerosis), RA, PAN.
7. Neoplasia - SCC (Marjolin’s), BCC, MM, Kaposi sarcoma, lymphoma.

Question 1

What is the prevalence of leg ulcers?

Answer 1

1-3% of the population.

Question 2

What is important in the history of the leg ulcer patient?

Answer 2

• onset of ulcer, time and mechanism.
• previous treatment .
• ambulatory status.
• footwear.
• symptoms e.g. claudication, rest pain.
• co-morbidities e.g. diabetes, smoking.

Question 3

‘Examine this leg (with a leg ulcer)’

Answer 3

1. Ulcer itself
   - venous ulcers: gaiter area, sloping edges.
   - arterial ulcers: toes, feet, ankles, ‘punched-out’ edges.
   - features of malignancy.
2. Circulation
   - temperature, cap refill.
   - peripheral pulses.
   - varicose veins, oedema, venous eczema, hyperpigmentation (venous disease).
3. Sensation
   - peripheral neuropathy: ‘glove and stocking’ distribution.

Question 4

How do you manage a patient with leg ulcers?

Answer 4

Wound swab - MC&S.
ABPI
Vascular studies
Radiology - Xray, CT (osteomyelitis?)
Biopsy - Marjolin's?
Rheumatology referral - vasculitis, connective tissue disorder?

Question 5

Tell me about venous ulcer disease.

Answer 5

• An area of epidermal discontinuity that persists for 4+ weeks, occurring as a result of venous hypertension and insufficiency of the calf muscle pump.

• 80% of lower limb ulceration.
• Venous hypertension may be caused by:
∘ Reflux of venous blood due to valvular incompetence
∘ Venous obstruction
∘ Insufficiency of the calf muscle pump.

• May affect the superficial system (L&SSV), deep system or interconnecting perforators.
• Valvular incompetence occurs due to thrombophlebitis, previous thrombosis or trauma.

• Venous hypertension may cause:
1 Protein-rich exudate to leak into subcutaneous tissue. Pericapillary fibrin cuff, causes local tissue hypoxia.
2 Extravasation of erythrocytes triggers an inflammatory response, with deposition of haemosiderin within macrophages.
- TGF-β may mediate dermal fibrosis, lipodermatosclerosis
and eventual ulceration.
- Lipodermatosclerosis is characterised by:
• Scarring
• Fibrotic, hyperpigmented skin
• ‘Inverted champagne bottle’ appearance.

Question 6

How do you manage venous leg ulcers?

Answer 6

Non-operative & Operative

Non-operative
1 Bed rest and leg elevation
2 Compression
3 Local treatments
4 Pentoxifylline (unlicensed indication).

Operative
1. Treat venous disease
• Ablation of superficial and perforating veins (open surgery or endovenous laser ablation.)
• Subfascial endoscopic perforating vein surgery (SEPS).
• Reconstruction of the deep venous system.

2. Treat ulcers
   • Debridement and skin grafting (High recurrence rate if underlying venous pathology is not corrected)
   • Excision with flap reconstruction (exceptional cases).

Question 7

Tell me about compression bandaging for venous ulceration.

Answer 7

Gold standard treatment for venous ulcers.

• Mean healing time = 5 months.
• recurrence rate = 30% in 5 years.

Four-layer bandaging enables the shortest time to healing.
- applied from toes to knee:
• Orthopaedic wool
• Crêpe bandage
• Elastic bandage
• Cohesive retaining layer.

or

Compression stockings classified as:
• Class 1 (light): 14-17mmHg
• Class 2 (medium): 18-24mmHg
• Class 3 (strong): 25-35 mmHg.

Question 8

What is the aetiology and risk factors for arterial ulcer disease?

Answer 8

• Results from reduced blood supply to the lower limb.
• Most common cause is atherosclerosis, risk factors include:
∘ Age
∘ Family history
∘ Smoking
∘ Diabetes
∘ Hypertension
∘ Hyperlipidaemia
∘ Obesity

Question 9

What are the signs associated with arterial ulcers?

Answer 9

• Generalised changes in the limb:
∘ Dusky erythema
∘ Lower surface temperature
∘ Lack of hair growth
∘ Thin, brittle, atrophic skin
∘ Thickened or missing toenails
∘ Absent peripheral pulses.

• Ulceration may develop after trivial trauma.

Question 10

How are arterial ulcers managed?

Answer 10

Combination of operative and non-operative methods.
Debridement or negative pressure wound therapy may enlarge the area of ischaemia.

Non-operative management
• Optimise patient e.g. diabetes, smoking
• Graded exercise regime
• Foot care
• Infection prevention
• Cilostazol or pentoxifylline.

Operative management
• Indications for invasive treatment:
∘ Non-healing ulceration
∘ Gangrene
∘ Rest pain
∘ Progression of disabling claudication.
• Aim to improve blood flow into the affected limb (accelerate healing time).
∘ Reconstructive vascular surgery or angioplasty.