Leg Ulcer Flashcards
DDx for leg ulcer
Venous ulcer (70%) Mixed arterial/venous ulcer Arterial ulcer Pressure ulcer Neuropathic ulcer (mainly with diabetes) Marjolin ulcer (SCC in an ulcer)
Which ulcers are MORE painful when the leg is elevated?
Arterial
Which ulcers are less painful when the leg is elevated?
Venous ulcers
However, only 30% are painful at all
Which ulcers are notoriously not painful at all?
Neuropathic
No nervous sensation to it!
Which ulcers are exquisitely tender?
Pressure ulcers
Long-standing ulcer could be a…
Marjolin ulcer
Could also be neuropathic or venous (these tend to present later than arterial)
Associated symptoms with venous ulcers
Chronic venous insufficiency -> varicose veins
Discoloured skin
Swelling and heavy feet
Pruritic stasis eczema
Associated symptoms with arterial ulcers
Any atherosclerosis stuff (TIA, stroke, claudication)
Any vascular insufficiency (e.g. cold extremities, weak pulses, hairless limbs, shiny)
NIGHT pain
How can a pelvic mass lead to increased risk of venous ulcers?
Can compress the iliac veins and cause poor venous return
Risk factors for atherosclerosis
Smoking HTN Alcohol Diabetes Family history Hyperlipidaemia
Recurrent DVTs can predispose to which type of ulcer?
Venous ulcer
Where do venous ulcers occur?
Where venous pressure is HIGH
Long sock distribution
Where do arterial ulcers occur?
Where arterial supply is the worst = distal foot, between toes
Ball of foot where there is pressure
Where do neuropathic ulcers occur?
Where there is repetitive trauma to the area with lost sensation = areas shoes catch
Base of big toe
Right side of little toe
Where do pressure ulcers occur?
On bony prominences e.g. sacrum
Features of neuropathic ulcers
Thick, keratinised walls
Raised edges surrounding them
Which, rare type of ulcer has a purple halo around it?
Pyoderma gangrenosum (IBD)
Which ulcer is associated with IBD?
Pyoderma gangrenosum
Erythrocytes can die in venous ulcers and cause what….
Haemosiderin staining
What is Buerger’s test?
Raise the leg at 45 degrees and it goes pale
Indicates arterial insufficiency
Distribution of neuropathic ulcers
Glove and stocking
Investigations for ulcers
Bloods (looking at anaemia that could impair healing)
Capillary glucose, checking for diabetes
Venous duplex ultrasound
How can you check the status of the venous system in the legs
Venous duplex ultrasound
What is ABPI?
Arterial brachial pressure index
What is the ABPI cut off for NOT bandaging a venous ulcer?
<0.8
What does an ABPI <0.8 suggest?
The ulcer is a mix of arterial and venous
DO NOT BANDAGE
If the ABPI is <0.5 what should you do?
Immediately refer to a vascular surgeon
What do palpable pulses indicate that the ABPI is most likely above?
0.8
Management of venous ulcer
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
Typical timeline of venous ulcer
6 months
80% healed in this time
With regular dressing changes
What constitutes critical limb ischaemia
Rest pain
Tissue loss
ABPI <0.5
What should you do with suspected critical limb ischaemia?
Urgent referral to a vascular surgeon
What investigations can be done in critical limb ischaemia?
Arterial duplex ultrasonography of lower limbs
Angiography (may also be curative)
Metformin can cause what change in pH?
Lactic acidosis
What should you NOT give for arterial ulcers?
Compression stockings
Surgical intervention for critical limb ischaemia
Angioplasty and stenting
Bypass surgery
Amputation
Features of acute limb ischaemia
6 Ps Painful Pale Pulseless Paralysed Perishingly cold Paraesthesia
What should you immediately do if you suspect acute limb ischaemia?
CALL THE VASCULAR SURGEON ON CALL
What can be done by the vascular surgeons in acute limb ischaemia?
Embolectomy Percutaneous thrombolysis Revascularisation angioplasty Bypass surgery Amputation
Management of neuropathic ulcer
Foot care = avoid tight-fitting shoes and repeated traumas! = refer to orthotics and podiatry
Manage diabetes
Debridement
Treat any infections
Main complication you worry about in neuropathic ulcers?
Infection
First line Ix for ?osteomyelitis?
x-ray
Signs of osteomyelitis on X-ray
Periosteal reaction
Bone deformity
Osteolysis
Where do you biopsy a Marjolin ulcer?
Peripherally
Management of pyoderma gangrenosum
Better management of UC
Good nursing care
Cause of confusion in the elderly
UTI
Management of pressure ulcers
Record the ulcer and grade it
Keep them moving
Relieve the ulcer with soft, moist, padded ulcer dressing
When should you consider surgery for varicose veins?
Symptomatic
Venous leg ulcers
Lower limb skin changes = pigmentation and lipodermatosclerosis (champagne bottling)
Surgical options for varicose veins
Avulsion (incision and pull it out)
Stripping
Radiofrequency ablation
Angioplasty risks
Infection
Haematoma
Haemorrhage
Reaction to sedative
Specific = Thrombosis/embolisation Perforation of artery Aneurysm at the surgical site Reaction to contrast dye
Which type of dressing for an arterial ulcer?
Hydrogel, keep it moist!
Hydrocolloid dressings can be used for which ulcers?
Neuropathic
Keeps moist and protected
Grade 3 pressure ulcer =
Skin loss, fat visible but no bone
Grade 1 pressure ulcer =
Non-blanching erythema of intact skin
Which factors can impair ulcer healing
Malnutrition
Anaemia
Smoking
Diabetes
Most important factor for venous ulcer healing?
Compression
Foot pulses not palpable with ulcer =>
Arterial ulcer
