Leg ulcer Flashcards
What are the ddx for leg ulcer?
Venous ulcer (most common)
Mixed arterial/venous ulcer
Pressure ulcer
Neuropathic ulcer
Which type of ulcers are less painful when elevated?
Venous
Arterial ulcers are caused by ichaemia to the leg. How does elevation affect the degree of pain
Elevation increases the pain in arterial ulcers
Which type of ulcers are not painful
Neuropathic ulcers
Describe the onset of venous vs arterial ulcers
Venous ulcers - present late (less painful). Often have long and recurrent history
Arterial ulcers present early (more painful)
A long history should raise suspicions of what type of ulcer
Marjolins ulcer
What complications arise from venous ulcers
Varicose veins, pruritic stasis eczema, discolouration of surrounding skin, ankle oedema/swollen ankles
What complications can arise from arterial ulcers
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
Neuropathic ulcers are associated with what symptoms
Sensory loss - causing an unsteady gait
What are the RFs for venous ulcers
Varicose veins, immobile patients, recurrent DVTs, pelvic masses which compress iliac veins, arteriovenous malformations, major joint replacement
What are the RFs for arterial ulcers
RFs for atherosclerosis, CAD, cerebrovascular disease
Alcohol abuse and diabetes mellitus may predispose to?
Neuropathic ulcers
What are RFs for pressure ulcers
Bedridden patient, immobilisation, poorly applied splints/braces/casts
Where do venous ulcers typically occur
Gaiter area the legs (area covered by a large sock) - often just above medial malleolus
Where do arterial ulcers often occur
Distal areas of the foot (e.g. between toes) or areas that are frequently compressed
Where do neuropathic ulcers often occur
In pressure areas where foot rubs on poorly fitting footwear (e.g. under metatarsal heads)
Where do pressure ulcers typically occur
Heel or overlying the malleoli in immobile patients
Describe the appearance of a venous ulcer
Shallow, wet, irregularly white fragile borders
Describe the appearance of an arterial ulcer
Deep, punched out, dry, elliptical
Calluses are a sign of what type of ulcer
Neuropathic or pressure ulcers
Pyoderma gangrenosum is associated with what condition?
What is its appearance like
Associated with IBD
Has a characteristic dark blue/purple halo around it
Absent weak pulses, poor capillary refill, venous guttering are signs of what type of ulcer
Arterial
What investigations should be done in someone with a suspected venous leg ulcer
- FBC, lipids
- Capillary glucose
- Urinalysis
- Venous duplex US
- ABPI - measured to exclude arterial disease as a cause of ulcer (ABPI <0.8 indicates mixed arterial/venous picture)
- Swabbing
- ?Biopsy
How is a venous stasis managed
- Nutrition - encourage healing
- Lifestyle modification - mobilise
- Leg elevation - reduce venous stasis in lower limb
- Compression bandages
- Elastic stockings
- Varicose vein surgery
What investigations should be done in suspected arterial ulcer
How are arterial ulcers managed
- Arterial duplex US
- ECG
- Fasting lipids, glucose, HbA1c, FBC
Dressing ulcer (prevent infection), analgesia, antibiotics Then do surgery: either angioplasty (with/out) stunting, bypass surgery, amputation
What are the 6 Ps of acute limb ischaemia
Painful, pale, pulseless, paralysed, perishingly cold, parasthaesia
Acute limb ischaemia = surgical emergency
How do you manage a neuropathic ulcer
- Foot care
- Manage diabetes
- Debridement
- Treat infections
If a chronic venous ulcer turns into a squamous cell carcinoma (as suggested if you see fungation), what is this ulcer called
Marjolin ulcer
Fungating ulcer suggests infection or malignancy
Marjolin ulcers are managed by wide excision and split skin grafting
