Leg Ulcer

Question 1

DDx for leg ulcer

Answer 1

Venous ulcer (70%)
Mixed arterial/venous ulcer
Arterial ulcer 
Pressure ulcer 
Neuropathic ulcer (mainly with diabetes)
Marjolin ulcer (SCC in an ulcer)

Question 2

Which ulcers are MORE painful when the leg is elevated?

Answer 2

Arterial

Question 3

Which ulcers are less painful when the leg is elevated?

Answer 3

Venous ulcers

However, only 30% are painful at all

Question 4

Which ulcers are notoriously not painful at all?

Answer 4

Neuropathic

No nervous sensation to it!

Question 5

Which ulcers are exquisitely tender?

Answer 5

Pressure ulcers

Question 6

Long-standing ulcer could be a…

Answer 6

Marjolin ulcer

Could also be neuropathic or venous (these tend to present later than arterial)

Question 7

Associated symptoms with venous ulcers

Answer 7

Chronic venous insufficiency -> varicose veins
Discoloured skin
Swelling and heavy feet
Pruritic stasis eczema

Question 8

Associated symptoms with arterial ulcers

Answer 8

Any atherosclerosis stuff (TIA, stroke, claudication)
Any vascular insufficiency (e.g. cold extremities, weak pulses, hairless limbs, shiny)
NIGHT pain

Question 9

How can a pelvic mass lead to increased risk of venous ulcers?

Answer 9

Can compress the iliac veins and cause poor venous return

Question 10

Risk factors for atherosclerosis

Answer 10

Smoking
HTN
Alcohol
Diabetes
Family history 
Hyperlipidaemia

Question 11

Recurrent DVTs can predispose to which type of ulcer?

Answer 11

Venous ulcer

Question 12

Where do venous ulcers occur?

Answer 12

Where venous pressure is HIGH

Long sock distribution

Question 13

Where do arterial ulcers occur?

Answer 13

Where arterial supply is the worst = distal foot, between toes
Ball of foot where there is pressure

Question 14

Where do neuropathic ulcers occur?

Answer 14

Where there is repetitive trauma to the area with lost sensation = areas shoes catch
Base of big toe
Right side of little toe

Question 15

Where do pressure ulcers occur?

Answer 15

On bony prominences e.g. sacrum

Question 16

Features of neuropathic ulcers

Answer 16

Thick, keratinised walls

Raised edges surrounding them

Question 17

Which, rare type of ulcer has a purple halo around it?

Answer 17

Pyoderma gangrenosum (IBD)

Question 18

Which ulcer is associated with IBD?

Answer 18

Pyoderma gangrenosum

Question 19

Erythrocytes can die in venous ulcers and cause what….

Answer 19

Haemosiderin staining

Question 20

What is Buerger’s test?

Answer 20

Raise the leg at 45 degrees and it goes pale

Indicates arterial insufficiency

Question 21

Distribution of neuropathic ulcers

Answer 21

Glove and stocking

Question 22

Investigations for ulcers

Answer 22

Bloods (looking at anaemia that could impair healing)
Capillary glucose, checking for diabetes
Venous duplex ultrasound

Question 23

How can you check the status of the venous system in the legs

Answer 23

Venous duplex ultrasound

Question 24

What is ABPI?

Answer 24

Arterial brachial pressure index

Question 25

What is the ABPI cut off for NOT bandaging a venous ulcer?

Answer 25

<0.8

Question 26

What does an ABPI <0.8 suggest?

Answer 26

The ulcer is a mix of arterial and venous | DO NOT BANDAGE

Question 27

If the ABPI is <0.5 what should you do?

Answer 27

Immediately refer to a vascular surgeon

Question 28

What do palpable pulses indicate that the ABPI is most likely above?

Answer 28

0.8

Question 29

Management of venous ulcer

Answer 29

Adequate nutrition (for appropriate healing) Mobilise and lose weight Leg elevation where possible Compression bandages applied and changed by an experienced nurse Once healed, can wear compression stockings Varicose vein surgery

Question 30

Typical timeline of venous ulcer

Answer 30

6 months 80% healed in this time With regular dressing changes

Question 31

What constitutes critical limb ischaemia

Answer 31

Rest pain Tissue loss ABPI <0.5

Question 32

What should you do with suspected critical limb ischaemia?

Answer 32

Urgent referral to a vascular surgeon

Question 33

What investigations can be done in critical limb ischaemia?

Answer 33

Arterial duplex ultrasonography of lower limbs | Angiography (may also be curative)

Question 34

Metformin can cause what change in pH?

Answer 34

Lactic acidosis

Question 35

What should you NOT give for arterial ulcers?

Answer 35

Compression stockings

Question 36

Surgical intervention for critical limb ischaemia

Answer 36

Angioplasty and stenting Bypass surgery Amputation

Question 37

Features of acute limb ischaemia

Answer 37

``` 6 Ps Painful Pale Pulseless Paralysed Perishingly cold Paraesthesia ```

Question 38

What should you immediately do if you suspect acute limb ischaemia?

Answer 38

CALL THE VASCULAR SURGEON ON CALL

Question 39

What can be done by the vascular surgeons in acute limb ischaemia?

Answer 39

``` Embolectomy Percutaneous thrombolysis Revascularisation angioplasty Bypass surgery Amputation ```

Question 40

Management of neuropathic ulcer

Answer 40

Foot care = avoid tight-fitting shoes and repeated traumas! = refer to orthotics and podiatry Manage diabetes Debridement Treat any infections

Question 41

Main complication you worry about in neuropathic ulcers?

Answer 41

Infection

Question 42

First line Ix for ?osteomyelitis?

Answer 42

x-ray

Question 43

Signs of osteomyelitis on X-ray

Answer 43

Periosteal reaction Bone deformity Osteolysis

Question 44

Where do you biopsy a Marjolin ulcer?

Answer 44

Peripherally

Question 45

Management of pyoderma gangrenosum

Answer 45

Better management of UC | Good nursing care

Question 46

Cause of confusion in the elderly

Answer 46

UTI

Question 47

Management of pressure ulcers

Answer 47

Record the ulcer and grade it Keep them moving Relieve the ulcer with soft, moist, padded ulcer dressing

Question 48

When should you consider surgery for varicose veins?

Answer 48

Symptomatic Venous leg ulcers Lower limb skin changes = pigmentation and lipodermatosclerosis (champagne bottling)

Question 49

Surgical options for varicose veins

Answer 49

Avulsion (incision and pull it out) Stripping Radiofrequency ablation

Question 50

Angioplasty risks

Answer 50

Infection Haematoma Haemorrhage Reaction to sedative ``` Specific = Thrombosis/embolisation Perforation of artery Aneurysm at the surgical site Reaction to contrast dye ```

Question 51

Which type of dressing for an arterial ulcer?

Answer 51

Hydrogel, keep it moist!

Question 52

Hydrocolloid dressings can be used for which ulcers?

Answer 52

Neuropathic | Keeps moist and protected

Question 53

Grade 3 pressure ulcer =

Answer 53

Skin loss, fat visible but no bone

Question 54

Grade 1 pressure ulcer =

Answer 54

Non-blanching erythema of intact skin

Question 55

Which factors can impair ulcer healing

Answer 55

Malnutrition Anaemia Smoking Diabetes

Question 56

Most important factor for venous ulcer healing?

Answer 56

Compression

Question 57

Foot pulses not palpable with ulcer =>

Answer 57

Arterial ulcer