Leg Ulcers Flashcards
What are causes of ulceration?
- Venous insufficiency
- Arterial insufficiencyy
- Neuropathy
- Diabetes
- Lymphoedema
- Vasculitis
- Malignancy
- Infection
- Trauma
- Drug induced
- Pyroderma gangrenosum
What are infective causes of ulceration?
- Fungi
- TB
- Syphilis
What is the definition of an ulcer?
A break in an epithelial surface
What different types of chronic venous insufficiency can lead to ulcer development?
- Previous DVT
- Varicose veins
- Combined deep and superficial insufficiency
- Congenital reflux
What aspects of the history would you want to know about an ulcer?
- Number
- Pain
- Trauma
- Co-morbidities
- Time period
- Healing/Recurrence
What would you note on examination of an ulcer?
- Site
- Temperature
- Shape
- Edge
- Base
- Depth
- Discharge
- Sensation
- Associated lymphadenopathy
- Phase of healing
- Pulses
If an ulcer had a sloped edge, what would that indicate?
The ulcer is healing
If an ulcer has a punched out appearence, what would that indicate?
Ischaemia or infection (syphilitic)
If an ulcer had an undermined appearence, what may that indicate?
- TB ulcer
- Decubitus Ulcer/Pressure Sore
If an ulcer had a rolled edge, what may that indicate?
Malignancy - basal cell cell carcinoma
If an ulcer had an everted edge, what may that indicate?
Malignancy - squamous cell carcinoma
What is slough?
Grey-yellow mucus which can line the base of an ulcer. It is a mixture of fibrin, cell breakdown products, exudate, leucocytes and bacteria
What is granulation tissue?
Deep pink gel-like matrix contained within a fibrous collagen network. This is evidence of wound healing
What other investigations would you consider if you found someone to have a lower limb ulcer?
- Examination - other signs of venous insufficiency
- Venous duplex ultrasound
- ABPI
- Ulcer biopsy - assess for vasculitis/malignancy if suspected
In terms of pain, what is the difference between an arterial and venous ulcer?
Arterial ulcers are painful unless neuropathic, whereas venous have minimal to no pain
What previous problems may someone have in the PMH which may indicate a venous ulcer?
- Previous DVT
- Severe varicose veins
What previous problems may someon have had which may indicate an arterial cause of a lower limb ulcer?
- Cardiac ischaemia
- Coronary artery bypass graft
In terms of swelling of the surrounding limb, how do arterial and venous ulcers differ?
- Arterial - not swollen unless sleeping in chair
- Venous - non-pitting/pitting oedema
How would a limb with an arterial ulcer differ from one with a venous ulcer in terms of temperature?
Arterial would be cold, whereas venous would be normal or warm
How would a limb with an arterial ulcer differ from one with a venous ulcer in terms of pulses?
Arteril - pulses would be absent
What kind of ulcers are found over the medial malleolus (gaiter area)?
Venous ulcer
Where do diabetic ulcers most commonly occur?
- Sole of the foot beneath metatarsal heads
- Bony prominences - toes, ball of great toe, malleoli
Where do arterial ulcers most commonly occur?
Anywhere below the mid-calf - can be anterior shin, heel or medial malleolus
What type of ulcer is the following?
Venous - gaiter area
What type of ulcer is the following?
Diabetic/ neuropathic foot ulcer
What type of ulcer is the following?
Diabetic - with Charcot’s arthropathy
What type of ulcer may the following be?
Arterial ulcer - colour changes in the foot, plus over anterior shin
What type of ulcer is the following?
Arterial - obvious signs of tissue necrosis
Should slough be removed from an ulcer?
No, unless arterial insifficiency can be excluded
What is characteristic about diabetic foot ulcers?
Penetrate deeply into the foot, where there is infected and necrotic tissue. They have a characteristic punched out edge with abrupt transition from normal to necrotic skin.
If the ulcer is on the sole, the edges become hyperkeratinised in response to excess pressure during walking caused by foot distortion and loss of sensation
What are local causes of unilateral limb swelling?
- Chronic venous insufficiency
- Congenital lymphatic aplasia/hypoplasia
- Acute venous obstruction - DVT
- Chronic cellulitis
What are local causes of bilateral leg swelling?
- Bilateral chronic venous insufficiency
- Lymphatic obstruction - filariasis
- Immobility
- Pregnancy
What are regional causes of bilateral leg swelling?
- LVH
- Pelvic mass obstucting venous return
- Inguinal/more proximal mass obstructing lymphatic return
- Filariasis
- IVC obstruction
What are systemic causes of bilateral limb swelling?
- CCF/RHF
- Hypalbuminaemia - malnutrition, nephrotic syndrome
- Fluid overload
How would you manage a venous leg ulcer?
Get expert nursing care
- Basic wound management - Non-adherent dressings
- Multilayered compression bandaging - only if arterial pulses ok!!!
- Consider medications - Analgesia, Diuretics
- Consider surgery
- Elevate limb
What is the cut-off ABPI score for using compression bandaging for a venous leg ulcer before referring for specialist advice?
If ABPI is <0.8, refer for specialist help
What methods can be used to debride sloughy necrotic tissue?
- Surgery
- Larval therapy
- Hydrogels
Why would you avoid hydrogels in diabetic foot ulcers?
Can propagate the development of wet gangrene
What are the different types of gangrene?
- Dry gangrene
- Wet gangrene
- Gas gangrene
What is dry gangrene?
A form of coagulative necrosis that develops in ischemic tissue, where the blood supply is inadequate to keep tissue viable. Dry gangrene is often due to peripheral artery disease, but can be due to acute limb ischemia.
What is wet gangrene?
Characterized by thriving bacteria and has a poor prognosis (compared to dry gangrene) due to sepsis resulting from the free communication between infected fluid and circulatory fluid.
In wet gangrene, the tissue is infected by saprogenic microorganisms (Clostridium perfringens or Bacillus fusiformis, for example), which cause tissue to swell and emit a fetid smell
What is gas gangrene?
Subset of necrotizing myositis caused by bacteria that produce gas within tissues. It can be caused by Clostridium, most commonly alpha toxin-producing C. perfringens, or various nonclostridial species.
Infection spreads rapidly as the gases produced by bacteria expand and infiltrate healthy tissue in the vicinity. Because of its ability to quickly spread to surrounding tissues, gas gangrene should be treated as a medical emergency.
What is the difference between wet and dry gangrene?
Wet gangrene is infected, whereas dry is not
What is important to remember when managing arterial leg ulcers?
Do not use compression bandaging
How would you treat someone with dry gangrene?
- Analgesia if painful
- Restore blood supply
- Consider amputation
How would you manage someone with wet gangrene?
- Analgesia
- Broad-spectrum IV Abx
- Surgical debridement
- Consider amputation
How would you manage someone with gas gangrene?
- Remove all dead tissue (may need amputation)
- BenPen +/- clindamycin
- Hyperbaric 02 therapy
How does gas gangrene present?
- Muscle swelling
- Pas production
- Sepsis
- Severe pain
- Myonecrosis
What are symptoms of a venous leg ulcer?
- Asymptomatic at first
- General discomfort/pain
- Oedema
- Itchy skin
What are the main causes of venous ulceration?
- Venous hypertension
- Incompetent valves
- Thrombosis
What would a venous ulcer look like on examination?
- Wound bed composed of red or pink granulation tissue
- Margins tend to be sloped
- Yellow slough or necrotic tissue on the surface of the wound.
- Classically over gaiter region
- Pitting Oedema
- Dry and flaky skin - surrounding ulcer
- Haemosiderin
What is the investigation of choice for suspected venous leg ulcer?
Venous duplex ultrasound
What are features of an arterial ulcer that you would see on examination?
- Wound bed often pale and dry
- Little granulation tissue - due to the restricted blood supply
- Wound margins - well demarcated and often described as having a punched out appearance
- Necrotic tissue - within the wound.
- Most commonly found around the toes or on top of the feet
- Surrounding skin pale and shiny
- Cool extremities - one side more than other in some cases
- Atrophic toe nails/Hair loss
- Pulseless/reduced cap refill
- Buerger’s positive
What is the investigation of choice when investigating suspected arterial leg ulcers?
ABPI - also duplex US and angiography
What are the main aspects to managing an arterial leg ulcer?
- Basic wound management
- Conservative therapy - risk factor modification e.g. smoking, statins, antiplatelets etc.
- Endovascular Stenting
- Surgery
What might you see on examination of a neuropathic ulcer?
- Painless
- Infection
- Most likely to occur on the plantar surfaces
- Variable margins - dependent on site
- Tissue - subcut, bone, ligament, joint capsule
- Gangrene
- Surrounding skin - signs of erythema, areas of callus
What mnemonic can be used to remember causes of leg ulcers?
VAIN PAIN
- Venous
- Arterial
- Infection
- Neuropathic
- Pressure sores
- Arthritis (Rheumatoid and polyarteritis nodosa)
- Inflammatory bowel disease/Injury
- Neoplastic
Key features of arterial ulcers
- PAINFUL
- Usually over toes and pressure areas
- Painful at rest
-
Signs
- Punched out ulcers
- Sloughy base
- Poor peripheal pulses and other signs of limb ischaemia
Key features of venous ulcers
-
Usually preceded by chronic skin changes
- Venou seczema
- Lipodermatosclerosis
- PAINLESS
- Usually in giaters area (ABOVE) medial malleolus
