Leg Ulcers

Question 1

What is the definition of a CHRONIC leg ulcer?

Answer 1

open lesion between the knee and ankle joint that remains unhealed for at least 4 weeks.

Question 2

What type of leg ulcer is most common?

Answer 2

60-80% of leg ulcers are venous in nature

Question 3

What other forms of leg ulcers can be developed by patients?

Answer 3

22% arterial disease
9% rheumatoid arthritis (due to defective neuropathy)
5% diabetic (due to defective neuropathy)
Mixed arterial venous disease 10-20%

Question 4

The prevalence of leg ulcers increases with age. True/False?

Answer 4

True

=> will become more of a problem with the ageing population

Question 5

Who is responsible for treatment of leg ulcers?

Answer 5

> 80% of chronic venous leg ulcers cared for in the community

12% community and secondary care

5% in-patient treatment

Question 6

What distressing symptoms may leg ulcers cause?

Answer 6

pain
leakage
smell
infection
social isolation

Question 7

How much does it roughly cost the NHS per year to treat 1 leg ulcer?

Answer 7

£1500 per annum to treat 1 leg ulcer

Question 8

Why do leg ulcers cost so much to treat?

Answer 8

By time patient presents, the degree of disease is extensive:

Delay in full assessment and diagnosis
Delay in ABPI’s or none at all
Delay in commencing compression
Lack of confidence in compression application
Expensive dressings and inappropriate use

Question 9

What other causes should you consider when examining a leg ulcer?

Answer 9

Venous
Arterial (or mixed arterio-venous)
Vasculitic
Malignant
Inflammatory
“Hydrostatic” - dependant limb

Question 10

What is the order of assessment in a patient with a leg ulcer?

Answer 10

Patient
leg
ulcer

Question 11

What background factors should you consider about the patient before thinking about their leg and ulcer?

Answer 11

Current medication
Social circumstances
Smoker past or present
Mobility
Pain
Sleep disturbance

Question 12

What is Lipodermatosclerosis and why is it important in the formation of a leg ulcer?

Answer 12

A sclerotic reaction to venous hypertension:
skin thickens
insufficient blood supply
more likely to form ulcer if trauma occurs

Question 13

Why does venous dermatitis occur?

Answer 13

the non-nutritious venous blood irritates the skin

Question 14

What ulcers can be found in the “gaiter area” ?

Answer 14

Venous

Question 15

What type of ulcers are commonly found further up the calf?

Answer 15

Arterial OR Skin cancers

Question 16

Where can pressure ulcers be found?

Answer 16

On the heels

patients get these if bedbound for significant amount of time

Question 17

What type of ulcers are common in the foot?

Answer 17

Diabetic due to lack of feeling

Question 18

What is slough?

Answer 18

skin debris and dead bacteria on top of ulcerated tissue

often yellow in colour

Question 19

What disease is Necrobiosis Lipoidica linked to?

Answer 19

Diabetes

Question 20

What are the most common causes of vasculitis?

Answer 20

Infection or drugs

Question 21

What is vasculitis?

Answer 21

group of disorders in which there are inflamed blood vessels

e.g. capillaries, arterioles, venules and lymphatics.

Question 22

Describe how vasculitis can present clinically

Answer 22

Painful
Sudden onset
Purpuric rash/pustules
Necrotic

Question 23

How would an arterial ulcer usually appear?

Answer 23

Hairless leg
Cool/pale leg
Painful
Sharp edge
Punched out lesion
Can sometimes see tendon (due to ulcer depth)

Question 24

Describe the difference between a normal and abnormal ABPI

Answer 24

<0.8 = vascular disease
~1 = normal
>1.5 = calcification **often noise is continually heard on Doppler as arteries wont compress due to extensive calcification**

Question 25

What differentials must be considered if a suspected venous ulcer is not healing with compression?

Answer 25

Basal cell carcinoma

Squamous cell carcinoma

Question 26

When would you swab an ulcerated wound?

Answer 26

Only if showing clinical signs of infection

=> ulcer increasingly painful/exudate/malodour/
enlarging

Question 27

At what point would a leg ulcer patient benefit from patch testing?

Answer 27

If they become allergic to previous ulcer treatments

eg. Bandages, dressings, creams

Question 28

What agents can be used to get rid of slough on a wound?

Answer 28

hydrogel
honey
Maggot therapy

Question 29

Leg elevation can help in the management of venous ulcers. Where should the leg be raised to?

Answer 29

Above hip height

Question 30

How are compression stockings graded?

Answer 30

Class 1(weak) to class 3 (strong).

Question 31

What shape should compression bandages aim to create on the leg?

Answer 31

Leg padded to a cone shape

Question 32

How often should a compression bandage be changed?

Answer 32

Weekly

Question 33

How long should it take to heal a venous ulcer through compression?

Answer 33

12 weeks

if not healed by then consider other differentials

Question 34

Can venous ulcers be healed by dressings?

Answer 34

No, the compression is what heals the ulcers

Question 35

How are wound beds usually prepped for further therapy?

Answer 35

Autolytic: The use of dressings to create moist wound environment and hydrate necrotic tissue

Sharp debridement: With scalpel or scissors

Biological: larvae therapy

Surgical: under general anaesthetic

Question 36

What other component is used as a barrier around the perimeter of the wound to stop it leaking during larvae therapy?

Answer 36

Zinc Oxide (ZnO)

Question 37

What is slough?

a) Healthy skin
b) Active infection
c) Skin debris and dead bacteria
d) Granulation tissue

Answer 37

C

Question 38

How can slough be removed?

a) Compression bandaging
b) Hydrogels
c) Manual debridement
d) All of the above

Answer 38

D

Question 39

Which ulcers should be swabbed?

a) All ulcers
b) Sloughy ulcers
c) Painful ulcers
d) Only those showing signs of clinical infection

Answer 39

D

Question 40

How should a leg ulcer be cleaned?

a) Warm tap water and soap substitute
b) Sterile saline solution
c) Hibiscrub
d) They shouldn’t be washed

Answer 40

A

Question 41

How should venous dermatitis be managed?

a) Apply regular emollients
b) Consider patch testing
c) Topical steroids
d) Compression bandages or stockings
e) All of the above

Answer 41

E

Question 42

Which of the following could be the cause of a non-healing leg ulcer?

a) Skin cancer
b) Inflammatory skin disease
c) Poor hygiene
d) a and b

Answer 42

D

Question 43

Which of these conditions are important in the management of leg ulcers?

a) Cardiovascular disease
b) Diabetes
c) Deep venous thrombosis
d) All of the above

Answer 43

D

Question 44

Why is ABPI performed?

a) To check for DVT
b) To examine the varicose veins prior to surgery
c) To assess the arterial system
d) To measure oxygen levels in the feet

Answer 44

C

Question 45

What shape are you aiming for when padding and shaping a leg prior to bandaging?

a) Oval
b) Rectangle
c) Cone
d) Triangle

Answer 45

C

Question 46

What is the most important therapy in healing venous leg ulcers?

a) Dressings
b) Antibiotics
c) Skin grafts
d) Compression

Answer 46

D

Question 47

Once a venous ulcer is healed, what should the patient be advised to do?

a) Nothing
b) Use regular emollient
c) Wear appropriate strength compression stockings
d) b and c

Answer 47

D

Question 48

How long do compression stockings last?

4-6 months
Forever
2 months
12 months

Answer 48

A