Leg Ulcers

Question 1

what is the time frame for a chronic ulcer

Answer 1

4 weeks

Question 2

outline venous insufficiency

Answer 2

improper functioning of one way valves causes pooling of blood and so increased venous pressure.

this causes fibrin deposits around the capillaries, which acts asa barrier to the flow of O2 and nutrients to the muscle and skin tissue.

death of tissue leads to ulceration

Question 3

describe venous ulcers

Answer 3

shallow, superficial, lots of exudate

irregular shape

sloping edges

Question 4

common locations of venous ulcers

Answer 4

malleoli, gaiter area

Question 5

what 2y features are seen in venous ulcers

Answer 5

lipodermatosclerosis - thickening of the skin (woody)

swollen ankles

varicose veins

slow growing, thick toe nails

haemosiderin staining occurs due to the breakdown of Hb

Question 6

why does venous dermatitis occur

Answer 6

fluid collects in the tissues and then activation of the immune response

causes red itchy skin

Question 7

what is venous dermatitis often mistaken for

Answer 7

cellulitis - more likely to be unilateral and have a port of infection

Question 8

venous dermatitis management

Answer 8

regular emollient, consider patch testing, topical steroids and compression bandages/stockings

Question 9

what are some risk factors for venous ulcer

Answer 9

DVT, varicose veins, incompetent veins, muscle weakness, obesity, pregnancy, malnutrition

Question 10

outline arterial insufficiency

Answer 10

poor blood circulation in lower leg due to athlerosclerosis where the arteries become narrowed by fatty deposits. arteries fail to deliver adequate O2 and nutrients

Question 11

describe arterial ulcers

Answer 11

full thickness wound - punched out appearance

skin is pale, taught and shiny

little hair growth, cold

wound bed contains bright red granulation tissue

Question 12

where are arterial ulcers most commonly found

Answer 12

areas of pressure eg toes feet and shins

Question 13

risk factors for arterial ulcers

Answer 13

inadequate footwear, vascular insufficiency, uncontrolled diabetes mellitus, high BP and cholesterol, smoking

Question 14

Necrobiosis Lipoidica

Answer 14

Rare granulomatous skin disorder that can affect the shin of insulin dependent diabetic patients.

Patch of spreading erythema over the shin which becomes yellowish and atrophic in the centre and may ulcerate.

Question 15

pyoderma gangrenosum

Answer 15

Condition of unknown aetiology that presents with erythematous nodules or pustules which frequently ulcerate. The ulcers can be large and grow at an alarming speed.

The ulcer has a typical bluish black (‘gangrenous’) undermined edge and a purulent surface (‘pyoderma’).

Part of a group of autoinflammatory disorders, seen in patients with IBD (UC and Crohn’s), rheumatoid arthritis, liver disease (PBC) etc.

Question 16

vasculitis

Answer 16

blood vessels destroyed by inflammation

Question 17

vasculitis CF

Answer 17

sudden onset, painful, purpuric rash/pustules and necrotic

Question 18

what would one use to identify arterial disease

Answer 18

• ABPI (also CPT and Buerger)
  
  • ABPI >0.8 to exclude arterial disease
• duplex scan - non invasive imaging of arteries and veins

Question 19

what would one do if infection was suspected

Answer 19

wound swab

Question 20

other investigations

Answer 20

bloods and patch testing

Question 21

reason for patch testing

Answer 21

to prevent reaction to topical treatments and bandages

Question 22

how can ulcers be cleaned

Answer 22

with warm tap water and soap substitute

Question 23

what is the time frame to aim to heal ulcers in

Answer 23

12 weeks (3 months)

Question 24

venous ulcer treatment

Answer 24

• control pain
• ABPI (>0.8 to exclude arterial disease)
• non-adherent dressing
• de-sloughing agent if necessary
• 4 layer compression banding
• leg elevation

Question 25

what is the most important therapy for venous ulcer

Answer 25

compression bandaging

Question 26

4 layer compression bandaging

Answer 26

• Graduated compression – 40mmHg below ankle and 18mmHg below knee
• Leg padded to a cone shape
• Changed weekly, or as required

Question 27

how can slough be remove

Answer 27

• autolytic:
  
  • the use of dressings to create a moist environment and hydrate necrotic tissue or eschar
  • eg hydrogel or honey
• sharp debridement
  
  • scalp or scissors
• biological
  
  • larvae
• surgical

Question 29

further venous ulcer treatment

Answer 29

infections - treated empirically with broad spectrum ABx untilk definitive sensitivities available

varicose eczema - topical steroids and emollients

Question 30

what malignancy can occur on top of chronic ulcers

Answer 30

SCC

Question 31

once healed, how are venous ulcers looked after

Answer 31

• leg elevation
• compression stocking to prevent recurrence
• calf/ankle exercises
• suitable diet

Question 32

what class of compression stocking is the strongest

Answer 32

3

Question 33

what class of compression stocking do patients normally wear

Answer 33

2

Question 34

are venous or arteiral ulcers more painful

Answer 34

arterial - particularly painful at night