Leg Ulcer Flashcards
List a differential diagnosis of leg ulcers.
Venous ulcers Mixed ulcers Arterial ulcers Neuropathic ulcers Pressure ulcers Lymphoedema ulcers Traumatic ulcers Vasculitic ulcers Marjolin’s ulcers
What type are the majority of leg ulcers?
Venous ulcers – 70%
List two key features of the ulcer history.
Is the ulcer painful?
How long has the ulcer been there?
What is a Marjolin’s ulcer?
A squamous cell carcinoma arising from chronically inflamed tissue
How does the pain differ in: Venous Ulcers Arterial Ulcers Neuropathic Ulcers Pressure Ulcers
- Venous Ulcers Not particularly painful Pain is relieved when the leg is elevated (because pain/ulcer is caused by venous stasis) - Arterial Ulcers Quite painful Pain is worse when the leg is elevated (because pain is due to ischaemia) - Neuropathic Ulcers NO pain - Pressure Ulcers Exquisitely tender Not necessarily painful
How does the time of presentation of ulcers differ in: Venous Ulcers Arterial Ulcers Neuropathic Ulcers Pressure Ulcers Marjolin Ulcers
- Venous Ulcers
Present late because they aren’t that painful
Tend to have long, recurring history - Arterial Ulcers
Present early because they are painful
Often present secondary to trivial trauma - Neuropathic Ulcers
Present late because they are not painful - Pressure Ulcers
Can develop surprisingly fast (especially in hospital because of bed rest) - Marjolin Ulcers
Long-history of an ulcer/chronic skin inflammation that has suddenly changed
List some key associated features of:
Venous Ulcers
Arterial Ulcers
Neuropathic Ulcers
- Venous Ulcers
Varicose veins
Skin changes: haemosiderin deposition, stasis dermatitis, lipodermatosclerosis
Ankle oedema - Arterial Ulcers
Peripheral vascular disease (e.g. claudication, night pain, rest pain)
Coronary artery disease (e.g. angina, SOBOE)
Cerebrovascular disease (e.g. stroke, TIA) - Neuropathic Ulcers
Sensory loss
Unstable gait
Infected ulcers (mainly in diabetics)
List risk factors for: Venous Ulcers Arterial Ulcers Neuropathic Ulcers Pressure Ulcers
- Venous Ulcers Presence of varicose veins Immobility Malnourishment Recurrent DVTs Pelvic mass compressing iliac veins AV malformations Major joint replacement (carries high subclinical DVT risk) - Arterial Ulcers Atherosclerosis risk factors: hypertension, diabetes, smoking, hypercholesterolaemia etc. - Neuropathic Ulcers Diabetes mellitus Alcohol abuse - Pressure Ulcers Long-term bed rest/ long lie
Describe the common sites of the following types of ulcer: Venous Ulcers Arterial Ulcers Neuropathic Ulcers Pressure Ulcers
- Venous Ulcers
Gaiter area of the legs (mainly above the medial malleolus)
This is where venous pressure is highest - Arterial Ulcers
Distal areas (e.g. between the toes) and frequently compressed areas (e.g. ball of foot) - Neuropathic Ulcers
Pressure areas (e.g. ball of foot) – because it is subject to repetitive trauma - Pressure Ulcers
Bony prominences that experience constant pressure (e.g. heel)
Describe the characteristics of:
Venous Ulcers
Arterial Ulcers
Neuropathic Ulcers
- Venous Ulcers Shallow Wet Irregular borders that look white and fragile - Arterial Ulcers Deep Dry Punched-out appearance Often elliptical - Neuropathic Ulcers Thick, keratinized raised edges surrounding the ulcer
Which diseases are associated with pyoderma gangrenosum?
Inflammatory bowel disease Blood dyscrasias (e.g. multiple myeloma)
Describe the typical appearance of pyoderma gangrenosum.
An ulcer with a characteristic purple halo around it
Venous ulcers can scar leading to white patches of scarred skin. What is this feature called?
Atrophie blanche
What is the term used to describe severe lipodermatosclerosis?
Inverted champagne bottle sign
Describe some features of the affected limb in a patient with arterial ulcers.
Cold Pale Absent/weak pulses Delayed capillary refill time Atrophic skin changes (dry, shiny, hairless)
What is Buerger’s test? Describe how it is performed and what a positive result indicates.
Whilst the patient is supine, raise the leg up until it goes pale
NOTE: in normal people, the leg should remain pink even at 90 degrees
The angle at which it goes pale is ‘Buerger’s angle’
Then the leg is put back down
With positive Buerger’s sign – the leg will slowly turn pink but then it will go red (this is due to reactive hyperaemia)
Describe some features of the affected limb in a patient with neuropathic ulcers.
Loss of sensation (gloves and stockings distribution) Foot deformities (e.g. Charcot foot)
Why would you check FBC in a patient with ulcers?
Anaemia could worsen the ischaemia that causes ulcers
List some other investigations that you would use in a patient with a suspected venous ulcer.
Fasting lipids Capillary glucose Urinalysis Venous duplex ultrasound – good for assessing saphenofemoral competence ABPI
Why is it important to calculate the ankle-brachial pressure index (ABPI) before treating an ulcer?
This allows assessment of arterial disease
ABPI < 0.8 – do NOT apply pressure bandage because it will worsen the ischaemia
Which ulcers may require a biopsy?
Marjolin’s ulcer
Outline the management of venous ulcers.
Adequate nutrition Leg elevation Compression bandages Elastic stockings Varicose vein surgery
Define critical limb ischaemia.
Severe obstruction of the arteries which markedly reduces blood flow to the extremities and has progressed to the point of causing severe pain, ulcers or gangrene. These patients will have rest pain.
List some investigations for suspected arterial ulcers.
Duplex ultrasonography – assess arterial patency Percutaneous angiography ECG Fasting lipids, glucose, HbA1c FBC
Outline the management of arterial ulcers.
Dress the ulcer to prevent infection
Analgesia
Antibiotics (if signs of infection)
List some surgical options for treating arterial ulcers.
Angioplasty
Bypass surgery
Amputation
What causes acute limb ischaemia?
A sudden lack of blood flow to a limb
What are the signs of acute limb ischaemia?
6 Ps of acute limb ischaemia: Pale Pulseless Painful Paralysis Paraesthesia Perishingly cold
List some possible interventions for acute limb ischaemia.
Embolectomy Percutaneous thrombolysis Revascularisation angioplasty Bypass surgery Amputation
Outline the treatment of neuropathic ulcers.
Foot care
Manage diabetes
Debridement of necrotic tissue
Treat infections
What is a major complication of neuropathic ulcers?
Osteomyelitis
Outline the management of pressure ulcers.
Record the ulcer
Relieve the ulcer
Reduce further ulcers
Reassess ulcer
List some surgical options for varicose veins.
Avulsion/phlebectomy
Stripping
Injection sclerotherapy
Radiofrequency ablation
