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Oxford Clinical Cases > Leg Ulcer > Flashcards

Leg Ulcer Flashcards

1
Q

DDx for leg ulcer

A 
Venous ulcer (70%)
Mixed arterial/venous ulcer
Arterial ulcer 
Pressure ulcer 
Neuropathic ulcer (mainly with diabetes)
Marjolin ulcer (SCC in an ulcer)
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2
Q

Which ulcers are MORE painful when the leg is elevated?

A

Arterial

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3
Q

Which ulcers are less painful when the leg is elevated?

A

Venous ulcers

However, only 30% are painful at all

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4
Q

Which ulcers are notoriously not painful at all?

A

Neuropathic

No nervous sensation to it!

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5
Q

Which ulcers are exquisitely tender?

A

Pressure ulcers

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6
Q

Long-standing ulcer could be a…

A

Marjolin ulcer

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

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7
Q

Associated symptoms with venous ulcers

A

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

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8
Q

Associated symptoms with arterial ulcers

A

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

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9
Q

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

A

Can compress the iliac veins and cause poor venous return

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10
Q

Risk factors for atherosclerosis

A 
Smoking
HTN
Alcohol
Diabetes
Family history 
Hyperlipidaemia
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11
Q

Recurrent DVTs can predispose to which type of ulcer?

A

Venous ulcer

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12
Q

Where do venous ulcers occur?

A

Where venous pressure is HIGH

Long sock distribution

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13
Q

Where do arterial ulcers occur?

A

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

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14
Q

Where do neuropathic ulcers occur?

A

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

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15
Q

Where do pressure ulcers occur?

A

On bony prominences e.g. sacrum

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16
Q

Features of neuropathic ulcers

A

Thick, keratinised walls

Raised edges surrounding them

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17
Q

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

A

Pyoderma gangrenosum (IBD)

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18
Q

Which ulcer is associated with IBD?

A

Pyoderma gangrenosum

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19
Q

Erythrocytes can die in venous ulcers and cause what….

A

Haemosiderin staining

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20
Q

What is Buerger’s test?

A

Raise the leg at 45 degrees and it goes pale

Indicates arterial insufficiency

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21
Q

Distribution of neuropathic ulcers

A

Glove and stocking

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22
Q

Investigations for ulcers

A

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

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23
Q

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

A

Venous duplex ultrasound

24
Q

What is ABPI?

A

Arterial brachial pressure index

25
Q

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

A

<0.8

26
Q

What does an ABPI <0.8 suggest?

A

The ulcer is a mix of arterial and venous

DO NOT BANDAGE

27
Q

If the ABPI is <0.5 what should you do?

A

Immediately refer to a vascular surgeon

28
Q

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

A

0.8

29
Q

Management of venous ulcer

A

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

30
Q

Typical timeline of venous ulcer

A

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

31
Q

What constitutes critical limb ischaemia

A

Rest pain
Tissue loss
ABPI <0.5

32
Q

What should you do with suspected critical limb ischaemia?

A

Urgent referral to a vascular surgeon

33
Q

What investigations can be done in critical limb ischaemia?

A

Arterial duplex ultrasonography of lower limbs

Angiography (may also be curative)

34
Q

Metformin can cause what change in pH?

A

Lactic acidosis

35
Q

What should you NOT give for arterial ulcers?

A

Compression stockings

36
Q

Surgical intervention for critical limb ischaemia

A

Angioplasty and stenting
Bypass surgery
Amputation

37
Q

Features of acute limb ischaemia

A 
6 Ps
Painful
Pale
Pulseless
Paralysed
Perishingly cold
Paraesthesia
38
Q

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

A

CALL THE VASCULAR SURGEON ON CALL

39
Q

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

A 
Embolectomy
Percutaneous thrombolysis
Revascularisation angioplasty
Bypass surgery
Amputation
40
Q

Management of neuropathic ulcer

A

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

41
Q

Main complication you worry about in neuropathic ulcers?

A

Infection

42
Q

First line Ix for ?osteomyelitis?

A

x-ray

43
Q

Signs of osteomyelitis on X-ray

A

Periosteal reaction
Bone deformity
Osteolysis

44
Q

Where do you biopsy a Marjolin ulcer?

A

Peripherally

45
Q

Management of pyoderma gangrenosum

A

Better management of UC

Good nursing care

46
Q

Cause of confusion in the elderly

A

UTI

47
Q

Management of pressure ulcers

A

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

48
Q

When should you consider surgery for varicose veins?

A

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

49
Q

Surgical options for varicose veins

A

Avulsion (incision and pull it out)
Stripping
Radiofrequency ablation

50
Q

Angioplasty risks

A

Infection
Haematoma
Haemorrhage
Reaction to sedative

Specific = 
Thrombosis/embolisation
Perforation of artery
Aneurysm at the surgical site
Reaction to contrast dye
51
Q

Which type of dressing for an arterial ulcer?

A

Hydrogel, keep it moist!

52
Q

Hydrocolloid dressings can be used for which ulcers?

A

Neuropathic

Keeps moist and protected

53
Q

Grade 3 pressure ulcer =

A

Skin loss, fat visible but no bone

54
Q

Grade 1 pressure ulcer =

A

Non-blanching erythema of intact skin

55
Q

Which factors can impair ulcer healing

A

Malnutrition
Anaemia
Smoking
Diabetes

56
Q

Most important factor for venous ulcer healing?

A

Compression

57
Q

Foot pulses not palpable with ulcer =>

A

Arterial ulcer

Oxford Clinical Cases (11 decks)

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