Leg Ulcer Flashcards
What are some differential diagnosis for a leg ulcer?
- venous ulcer (70%)
- mixed arterial/venous ulcer (10%)
- arterial (atherosclerotic) ulcer (10%)
- pressure ulcer
- neuropathic ulcer
- lymphoedema ulcer
- traumatic ulcer
- malignant ulcer (e.g. Marjolin ulcer, squamous cell carcinoma is long standing ulcer)
- vasculitic ulcer (e.g. rheumatoid arthritis, pyoderma gangrenosum)
- infective ulcer (e.g. TB, syphilis, leprosy)
- haemolytic anaemia (sickle cell, hereditary spherocytosis
What must be asked in the history of a leg ulcer?
- painful
2. how long been there
What is a venous ulcer caused by?
stasis in leg
What is an arterial (atherosclerotic) ulcer caused by?
ischaemia to leg
What is a pressure ulcer caused by?
prolonged pressure on affected site
What sort of pain does a venous ulcer cause?
less painful when elevated and drained of blood - but only 30% painful
What sort of pain does an arterial ulcer cause?
more painful when elevated and drained of blood - so painful wake up at night to hang leg over bed
What sort of pain do neuropathic ulcers cause?
loss of sensation (predisposes to constant trauma) so are not painful
What sort of pain do pressure ulcers cause?
tender but not necerssarily painful if no pressure is being applied
What sort of history do venous ulcers present with?
less painful so present later - long and recurring history
What sort of history do arterial ulcers present with?
relatively early due to pain, occur often secondary to trivial trauma
What sort of history do neuropathic ulcers present with?
assoicated with loss of sensation so present later
What sort of history do pressure ulcers present with?
can be short or long
What does a long history make you sus of?
Marjolin ulcer
What associated symptoms should you ask about with venous ulcers?
- varicose veins
- pruritic stasis eczema
- discoloration of surrounding skin
- haemosiderin deposition
- stasis dermatitis
- lipodermatosclerosis can occur
- ankle oedema (heavy feet)
What associated symptoms should you ask about with arterial ulcers?
ask about peripheral artery disease, coronary artery disease and cerebrovascular disease
- claudication
- night pain
- rest pain
- cold extremities
- angina
- SOB on exertion
- history of stroke or TIA
What must you ask about and why with arterial ulcers?
unusual to develop arterial ulcers without preceeding history of severe claudication and night pain so ask patients how far they can walk without pain in calves
What associated symptoms do you ask about with neuropathic ulcer?
- sensory loss
- unsteady gait
- foul smell if secondary infection
What are risk factors in history for venous ulcers?
- varicose veins, immobile/malnourished
- recurrent DVT
- pelvic mass (compressing iliac veins)
- arterivenous malformation (increasing venous pressure)
- major joint replacement
What are risk factors in history for arterial ulcers?
- smoking
- DM
- hypertension
- hyperlipididaemia
- male
- FHx of atherosclerotic disease
- Coronary artery disease
- TIA/Stroke
- Claudication
- Impotence
- AAA
What are risk factors in the history for neuropathic ulcers?
- DM
2. Alcohol overuse
What are risk factors in the history for pressure ulcers?
- bedridden due to frailty or sickness
- immobilized (intesive care)
- poorly applied splints, braces and plaster casts
What are you looking for on the examination of a leg ulcer?
- Site
- Characteristics
- Associated signs
Where are venous ulcers usually located?
gaiter area of legs (just above medial malleolus)
Where are arterial ulcer usually located?
distal area of foot and those frequently compressed (ball of foot, between toes, tips of toes, lateral malleolus)
Where are neuropathic ulcers usually located?
repetitive trauma so in pressure areas where foot rubs on poorly fitting footwear e.g. beneath metatarsal head
Where are pressure ulcers usually located?
bony prominences, heel or overlying the malleoli in immobile, bedridden patients
What are the common characteristics of venous ulcers?
- shallow
- wet
- irregular white fragile borders
What are the common characteristics of arterial ulcers?
- well defined
- deep punched out
- dry
- often elliptical
What are the common characteristics of neuropathic and pressure ulcers?
raised callous edges
What are the common characteristics of pyoderma gangrenosum ulcers?
dark blue/purple halo around it
What conditions are pyoderma gangrenosum ulcers often associated with?
IBD or haemotological malignancies
What are associated signs on examination of venous ulcers?
- oedema
- extravasation
- skin pigmentation from haemosiderin staining
- atrophie blanche
- lipodermatoscelrosis
- ankle flare
What are the associated signs of arterial ulcers on examination?
- Cold
- Hairless
- Dry skinned limb
- Weak or absent pulses
- Poor cap refill
- Venous guttering
- Beurger’s test positive
- Carotid bruits
- Abdominal aortic and/or popliteal aneurysms
If pulses are not palpable what must you use?
handheld doppler and calculate ankle-brachial pressure
What are the associated signs of a neuropathic ulcer on examination?
- Vibration and proprioception lost before other modalities
- Glove and stocking distribution of peripheral sensory neuropathy
- Foot deformities from motor neuropathy or repetitive joint trauma secondary to sensory neuropathy (Charoct joints)
What are the associated signs of pressure ulcer on examination?
- immobile patient
2. check for pressure ulcers on sacrum or buttocks
When do you check for inguinal lymphadenopathy with a leg ulcer?
if suspect infection or malignancy as cause of ulcer
What are the first line investigations for a leg ulcer?
- Bloods
- Cap glucose
- Urinalysis
- Venous duplex US
- Ankle-brachial pressure index (ABPI)
- Swabbing
- Biopsy
What bloods do you do?
- FBC
2. Fasting lipid
Why do you do a FBC?
anaemia exacerbating ischaemia and contributing to delayed healing
Why do you do a fasting lipid?
hyperlipidaemia contributing to any atherosclerotic disease
Why do you do a cap glucose?
check in undiagnosed DM
Why do you do urinalysis?
- look for glucose (DM)
2. if vasculitis considered: haematuria/proteinuria
Why do you do a venous duplex US?
gold standard to investigate and assess competence of saphenofemoral and saphenopoplitwal junctions and state of the perofrators and deep venous system
Why do you measure the ABPI?
- exclude arterial disease as cause
- even if sure venous ulcer
What is the ABPI?
ratio of ankle systolic pressure over brachial artery systolic pressure
What does an ABPI <0.8 suggest?
patient must not have a pressure bandage applies as ulcer mixed arterial and venous and compression makes arterial ischaemia worse
What does an ABPI of <0.5 or sudden change suggest?
need urgent referral to vascular surgeon
When do you swab an ulcer?
- for MCandS
2. useful in case of spreading cellulitis
When do you take a biopsy of an ulcer?
if suspect unsual cause e.g. Marjolin’s ulcer
What does the management of a venous ulcer involve?
- Adequate nutrition - key vitamins (C and zinc)
- Lifestyle modifications - encourage mobilising and obese patient loose weight
- Leg elevation: to reduce venous stasis in lower lib
- Compression bandages: applies and frequently changes by nurse to avoid pooling of venous blood in lower limb esp if ABPI >0.8
- Graduated class I or II elastic stockings: helpful once venous ulcer healed to prevent reccurence
- Varicose vein surgery: helpful to prevent reccurence if there is venous duplex evidence of an incompetence superficial venous system and there is no deep vein incompetence
How long does it take for a venous ulcer to heal?
with correct management 80% heal within 6months
