Leg ulcer

Question 1

What are the ddx for leg ulcer?

Answer 1

Venous ulcer (most common)
Mixed arterial/venous ulcer
Pressure ulcer
Neuropathic ulcer

Question 2

Which type of ulcers are less painful when elevated?

Answer 2

Venous

Question 3

Arterial ulcers are caused by ichaemia to the leg. How does elevation affect the degree of pain

Answer 3

Elevation increases the pain in arterial ulcers

Question 4

Which type of ulcers are not painful

Answer 4

Neuropathic ulcers

Question 5

Describe the onset of venous vs arterial ulcers

Answer 5

Venous ulcers - present late (less painful). Often have long and recurrent history

Arterial ulcers present early (more painful)

Question 6

A long history should raise suspicions of what type of ulcer

Answer 6

Marjolins ulcer

Question 7

What complications arise from venous ulcers

Answer 7

Varicose veins, pruritic stasis eczema, discolouration of surrounding skin, ankle oedema/swollen ankles

Question 8

What complications can arise from arterial ulcers

Answer 8

Symptoms of PAD, CAD or cerebrovascular disease. Symptoms include claudication, night pain, rest pain, cold extremeties, angina or SOB on exertion, stroke/TIA history.

Useful to ask patients how far they can walk without pain in their calves

Question 9

Neuropathic ulcers are associated with what symptoms

Answer 9

Sensory loss - causing an unsteady gait

Question 10

What are the RFs for venous ulcers

Answer 10

Varicose veins, immobile patients, recurrent DVTs, pelvic masses which compress iliac veins, arteriovenous malformations, major joint replacement

Question 11

What are the RFs for arterial ulcers

Answer 11

RFs for atherosclerosis, CAD, cerebrovascular disease

Question 12

Alcohol abuse and diabetes mellitus may predispose to?

Answer 12

Neuropathic ulcers

Question 13

What are RFs for pressure ulcers

Answer 13

Bedridden patient, immobilisation, poorly applied splints/braces/casts

Question 14

Where do venous ulcers typically occur

Answer 14

Gaiter area the legs (area covered by a large sock) - often just above medial malleolus

Question 15

Where do arterial ulcers often occur

Answer 15

Distal areas of the foot (e.g. between toes) or areas that are frequently compressed

Question 16

Where do neuropathic ulcers often occur

Answer 16

In pressure areas where foot rubs on poorly fitting footwear (e.g. under metatarsal heads)

Question 17

Where do pressure ulcers typically occur

Answer 17

Heel or overlying the malleoli in immobile patients

Question 18

Describe the appearance of a venous ulcer

Answer 18

Shallow, wet, irregularly white fragile borders

Question 19

Describe the appearance of an arterial ulcer

Answer 19

Deep, punched out, dry, elliptical

Question 20

Calluses are a sign of what type of ulcer

Answer 20

Neuropathic or pressure ulcers

Question 21

Pyoderma gangrenosum is associated with what condition?

What is its appearance like

Answer 21

Associated with IBD

Has a characteristic dark blue/purple halo around it

Question 22

Absent weak pulses, poor capillary refill, venous guttering are signs of what type of ulcer

Answer 22

Arterial

Question 23

What investigations should be done in someone with a suspected venous leg ulcer

Answer 23

1. FBC, lipids
2. Capillary glucose
3. Urinalysis
4. Venous duplex US
5. ABPI - measured to exclude arterial disease as a cause of ulcer (ABPI <0.8 indicates mixed arterial/venous picture)
6. Swabbing
7. ?Biopsy

Question 24

How is a venous stasis managed

Answer 24

1. Nutrition - encourage healing
2. Lifestyle modification - mobilise
3. Leg elevation - reduce venous stasis in lower limb
4. Compression bandages
5. Elastic stockings
6. Varicose vein surgery

Question 25

What investigations should be done in suspected arterial ulcer

How are arterial ulcers managed

Answer 25

1. Arterial duplex US
2. ECG
3. Fasting lipids, glucose, HbA1c, FBC

Dressing ulcer (prevent infection), analgesia, antibiotics
Then do surgery: either angioplasty (with/out) stunting, bypass surgery, amputation

Question 26

What are the 6 Ps of acute limb ischaemia

Answer 26

Painful, pale, pulseless, paralysed, perishingly cold, parasthaesia

Acute limb ischaemia = surgical emergency

Question 27

How do you manage a neuropathic ulcer

Answer 27

1. Foot care
2. Manage diabetes
3. Debridement
4. Treat infections

Question 28

If a chronic venous ulcer turns into a squamous cell carcinoma (as suggested if you see fungation), what is this ulcer called

Answer 28

Marjolin ulcer

Fungating ulcer suggests infection or malignancy

Marjolin ulcers are managed by wide excision and split skin grafting