Leg Ulceration Flashcards
causes of leg ulceration (8)
-venous disease - eg venous hypertention this accounts for 85% leg ulcers and has a prevelence of 1%. focus of this deck
-arterial disease - eg atherosclerosis
-small vessel disease - eg DM
-abnormalities of blood
-neuropathy -eg DM
-infection
-tumour
-trauma
- normal venous drainage of leg - requires what types of veins (3).
- stages of normal venous draingage (2)
- normal venous drainage requires superficial vvs, deep veins and commicating/performating veins connecting these.
1) calf mms relax - blood drains from sup to deep. valves prevent reflux.
2) calf mms contract - blood in deep vvs pushed back up to heart. valves prevent reflux.
- if normal drainage distrupted what stages of pathology occur (5)
1) instead of blood being pushed back to heart it is pushed into superficial vvs
2) causes venous hypertension in sup vvs. pressure remains high during exercise rather than falling
* 3*) with this persistant htn capilliary beds enlarge
4) white cells accumulate here and are activated and release free radicals and tocix products
5) local tissue destruction and ulceratiopn
-risk factors for disruption of normal drainage (2)
-risk factors for disruption of normal drainage
-incompetent valves-post dvt ,genetic
-poor mm pumping/inactivity - obesity, arthritis, bed bound,paralysis
- what perpetuates ulcer - bio (1)
- environmental (3)
- healing is complicated because htn forces fibrinogen and a2macroglobulin out thorugh capillary walls. these macromolecules trap growth and repair facotrs so minor traumatic wounds cannot be healed.
- pressure lying in bed, shearing forces and friction sliding down bed, moisture
-clinical features of venous htn ulcer (6)
- feeling of heaviness in legs
- pitting oedema
- red or blueish discolouration
- hair loss
- brown pigmentation due to breakdown of rbc and scattered petechiae
- atrophie blanche white scarring w. dilated capilliary loops
- induration fibrous tissue. sometimes called lipodermatosclerosis
venout htn ulcer v. atherosclerotic leg ulcer
-llocation. common location for venous (1) common location for athero(5)
- appearance. venous (3) arterial (3)
- extra signs. venous (1). arterial (2)
-location
>venous common near medial malleolus. relation to vvs
- >*arterial common toes, dorsum foot, heal, calf, shin
- appearance
>venous larger and shallower. may have granulation tissue in base
>arterial rounder and deeper. punched out appearance.
extra signs
>venous - incompetent perforating branches may be felt when pt is standing blow outs
>arterial - claudication. absent pulses
venous htn ulcer - complications (4)
- infection - bacterial colonization inevitable in chornic ulcer
- eczema - common around ulcer
- allergic contact dermatitis - caused by Rx with parabens, lanolin, neomycin. common, suspect if rash worsens, itches or fails to imporve with Rx.
-malignant change to scc. - hyperplastic or rolled edge. biopsy
investigations (5)
-blood glucose dm could affect healing
- FBC anaemia could delay healing
- swabbing
- venography, colour flow duplex scanning, abulatory venous pressure
- detect surgically remediable causes of benous incompetence*
-doppler US
assess arterial circulation when atherscelrosis is likely. nb arterial diease can contribute to worse healing
venous htn ulcers - Mx
will not heal if pt remains inactive. last resort is hopsital admission.
-physical measures (5)
-compression bandages and stockings nb must avoid this in atheroscleritic ulcers where blood supply already comprimised
-elevation of limb
-activity > walking and physio
-weight loss
- how is pressure graduated in compression bandaging
- purpose
- how long can bandages stay on for
- where do they cover
- what are they comprised of
- once ulcer is healed what is used
- compression is graduated so it is greatest at ankle and least at top.
- reduces oedema and aids venous return
- 2-7 days
- applied over ulcer dressing from forefoot to just below knee
- comprise of othopedic wool underneath 2-3 extensible badages
- once healed graduated compression stocking from toes to knees can be worn
venous htn ulcers - Mx
-local therapies (5)
use topical Rx, impregnated dressings to
-preparations to absorb excess exudates
-analgesic preperations
-preperations to protect surrounding skin from eczema
-antibiotic preperations for infected
-preperations to clean infected ulcers
venous htn ulcers - Mx
- oral therapies (6)
- surgery is also an option
- diuretics oedema
- analgesics
- antibiotics bad infection
-ferrous sulphate and folic acid anaemia
-zinc sulphate promote healing
-pentoxyfylline promote healing
