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Y2 MECHANISMS OF DISEASE > Leg Ulcers > Flashcards

Leg Ulcers Flashcards

1
Q

What is the definition of an ulcer?

A

A local defect, or excavation of the surface of an organ or tissue that is produced by sloughing of inflammatory necrotic tissue

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2
Q

What is the definition of an ulcer in relation to the skin?

A

the loss of an area of epidermis and dermis to produce a defect, even down to fat, muscle, tendons and bone

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3
Q

What is meant by ‘erosion’?

A

the loss of an area of epidermis

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4
Q

What are the main 4 causes of leg ulcers?

A
  1. traumatic
  2. vascular
  3. inflammatory
  4. neuropathic
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5
Q

What % of leg ulcer causes are arterial and venous?

A

70% are venous

10% are arterial

10% are mixed

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6
Q

What is calcinosis cutis?

A

calcium deposition in the skin

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7
Q

How is calcinosis cutis usually brought about?

A

damaged/inflamed skin prometes deposition of calcium in patients with disordered metabolism of calcium and phosphate

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8
Q

What pre-existing condition is present in most patients that contract calcinosis cutis?

A

hypercalcaemia

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9
Q

What are 2 diseases that are inflammatory causes of leg ulcers?

A
  1. pyoderma gangrenosum

2. panniculitis

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10
Q

What is a disease that is a neuropathic cause of leg ulcers?

A

peripheral neuropathy

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11
Q

What are examples of diseases that are malignant causes of leg ulcers?

A

SCC, BCC and lymphoma

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12
Q

What are examples of diseases that are vascular causes of leg ulcers?

A
  1. vasculitis and CTD

2. occlusive disease

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13
Q

What are examples of iatrogenic causes of leg ulcers?

A
  1. pressure sores

2. drugs - hydroxyurea and warfarin

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14
Q

What are examples of diseases that are metabolic causes of leg ulcers?

A
  1. diabetes mellitus

2. calcinosis cutis

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15
Q

What are examples of traumatic events that can cause leg ulcers?

A

usually chemical, thermal, electrical or radiation burns

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16
Q

Which category is mostly affected by venous leg ulcers?

A

middle aged to elderly women

they affect 1% of the population

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17
Q

What % of venous leg ulcers are recurrent?

A

70%

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18
Q

What are the 3 main risk factors for venous leg ulcers?

A
  1. valvular incompetence
  2. previous damage to venous system (e.g. DVT, hypertension)
  3. obesity & immobility
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19
Q

Why does obesity and immobility lead to venous leg ulcers?

A

Poor muscle contraction leads to venous pooling and hypertension

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20
Q

What is the definition of a chronic venous leg ulcer?

A

an open lesion between the knee and the ankle joint that remains unhealed for at least 4 weeks and occurs in the presence of venous disease

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21
Q

What lifestyle related factors may contribute to venous leg ulcers?

A
  1. sitting or standing for long periods
  2. obesity
  3. increasing age and immobility
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22
Q

What factors relating to the legs may be useful to hear in a history when looking at venous leg ulcers?

A
  1. history of leg swelling

2. end of day throbbing and aching in calf muscles

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23
Q

What factors relating to the veins may be useful to hear in a history when looking at venous leg ulcers?

A
  1. varicose veins
  2. history of blood clots in deep veins
  3. previous surgery
  4. previous fractures or injuries
    (3. and 4. can lead to vein damage and immobility)
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24
Q

What other factors may be useful to hear in a history for venous leg ulcers?

A
  1. high blood pressure

2. multiple pregnancies as this increases circulating volume

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25
Q

Upon examination, what are the signs of a venous leg ulcer?

A

superficial, sloughy with ill defined borders

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26
Q

Where is the most common place to develop a venous leg ulcer?

A

medial gaiter area

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27
Q

How painful are venous leg ulcers?

A

generally less painful than arterial leg ulcers

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28
Q

When performing an examination of a venous leg ulcer, what other signs should be looked for?

A

associated signs of chronic venous hypertension

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29
Q

What are the 5 associated signs of chronic venous hypertension?

A
  1. venous flare
  2. lipodermatosclerosis
  3. varicose veins
  4. atrophie blanche
  5. varicose eczema
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30
Q

What is lipodermatosclerosis?

A

an inflammatory skin condition resulting from underlying venous insufficiency

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31
Q

How does lipodermatosclerosis develop?

A
  1. venous hypertension causes an increase in leukocytes in the vein
  2. leukocytes migrate to surrounding tissue
  3. leukocytes are activated and attract and release proinflammatory cells and cytokines
  4. this induces a chronic inflammatory state
32
Q

What is the final stage in development of lipodermatosclerosis?

What is it commonly misdaignosed as?

A

Increased collagen production leads to the fibrosis of subcutaneous fat

Commonly misdiagnosed as cellulitis

33
Q

What are arterial ulcers often associated with?

A

peripheral vascular disease

34
Q

What happens in peripheral vascular disease?

A
  1. a plaque builds up in the arteries that carry blood to the lower limbs
  2. the plaque hardens and narrows the arteries
  3. the flow of blood to the lefs is limited
35
Q

What is the plaque made up of in peripheral vascular disease?

A

fat, cholesterol, calcium, fibrous tissue and other substances in the blood

36
Q

In general, what are the risk factors for arterial ulcers?

A

anything that causes cardiovascular or peripheral vascular disease

37
Q

What 4 things should be looked for in the history of someone with an arterial ulcer?

A
  1. intermittent claudication
  2. rest pain or paraesthesia
  3. pain at ulcer site
  4. other symptoms of vascular disease
38
Q

what is paraesthesia?

A

an abnormal sensation, typically tingling or pricking (‘pins and needles’), caused chiefly by pressure on or damage to peripheral nerves

39
Q

What is claudication?

A

a condition in which cramping pain in the leg is induced exercise

It is typically caused by obstruction of the arteries

40
Q

What signs will be seen in clinical examination of an arterial ulcer?

A
  1. punched out painful ulcer
  2. loss of hair appendages
  3. dry skin
  4. cool peripheries
  5. pale or cyanotic or pre-gangrenous toes
41
Q

Where are arterial ulcers usually seen?

A

On the lower leg and foot

42
Q

What is meant by Buerger’s sign?

What is it used to detect in arterial ulcers?

A

the angle to which the leg has to be raised before it becomes pale

used to detect position dependent ischaemia

43
Q

How do arterial ulcers affect pulse?

A

reduction in proximal and/or peripheral pulses with or without bruit

44
Q

What are the 5 P’s of PVD?

A
  1. pain
  2. pulseless
  3. paraesthesia
  4. painful
  5. paralysis
45
Q

What does a neuropathic ulcer look like and where is it usually found?

A

Found under metatarsal heads/heel

It is painless but warm with pulses

46
Q

What is a neuropathic ulcer due to?

A

distal polyneuropathy

47
Q

What are the causes of neuropathic ulcers?

A

the main cause is diabetes

other causes are:

  1. alcohol
  2. B1/B12 deficiency
  3. Charcot Marie Tooth disease
48
Q

What type of ulcer is pyoderma gangrenosum?

A

it is an inflammatory ulcer

it is one of a number of neutrophilic dermatoses

49
Q

What 3 conditions is pyoderma gangrenosum associated with?

A
  1. inflammatory bowel disease (Crohns, UC)
  2. rheumatoid arthritis
  3. monoclonal gammopathy
50
Q

In what % of cases is the cause for pyoderma gangrenosum identified?

A

In 50% of cases, the cause is not identified

51
Q

What does pyoderma gangrenosum look like initially and as it progresses?

A

It starts as an initial pustule

It rapidly breaks down into a painful rapidly spreading ulcer

52
Q

What is the appearance of the ulcer base and margins in pyoderma gangrenosum?

A

The base of the ulcer is dark red/dusky in colour

The margins are overhanging and purple/bluish

53
Q

Where is pyoderma gangrenosum most commonly found?

A

Most common on the anterior shin

It is also seen on the abdomen next to stoma sites

54
Q

What is significant about the appearance of a malignant ulcer?

A

It has rolled edges

55
Q

In which 2 ways can a malignant ulcer occur?

A

it can occur as a primary malignant lesion

it can also occur secondarily to a chronic ulcer

56
Q

How is a malignant ulcer diagnosed?

A

through excision and biopsy

57
Q

What are the indications for a biopsy of a leg ulcer?

A
  1. if it is a clinically atypical ulcer

2. to exclude or diagnose a malignancy

58
Q

Does an ulcer heal by first or second intention?

Why?

A

it heals by second intention

there is tissue loss and the margins of the wound are not apposed

59
Q

What are the 5 steps involved in healing of an ulcer by second intention?

A
  1. phagocytosis to remove debris
  2. granulation tissue fills in the defects and repairs specialised tissues lost
  3. organisation
  4. epithelial regeneration and early fibrous scar
  5. scar contraction
60
Q

What chemicals are involved in controlling healing and repair?

A

there is a complex interplay of various cytokines

61
Q

What are the 3 stages involved in management of a leg ulcer?

A
  1. treat the underlying cause of the ulcer
  2. treat the ulcer
  3. treat any associated infection
62
Q

What are ankle brachial pressure indices used to measure?

A

it is a type of doppler that measures the ankle brachial pressure index (ABPI)

63
Q

What is the ankle brachial pressure index?

A

the ratio of systolic blood pressure to occlude dorsalis pedis on doppler compared to systolic pressure of the ipsilateral upper arm

64
Q

Why is an ankle brachial pressure index used?

A

To assess how much compression can be applied

65
Q

What does an ABPI value <0.5 suggest?

A

there is significant arterial disease

66
Q

What does an ABPI value of 0.5-0.9 suggest?

A

claudication

67
Q

What does an ABPI value >1.0 suggest?

A

non-significant arterial disease

68
Q

What ABPI values indicate how much compression can be applied?

A

0.7-0.8 is okay for light compression

> 1.0 is okay for tight compression

69
Q

Why are patch tests used in CVLU patients?

A

many have contact dermatitis to many topical preparations or dressings used in leg ulcers

70
Q

Which types of CVLU patients should be considered for patch testing?

A

leg ulcer patients with dermatitis/eczema

71
Q

Why may a bone scan or MRI be needed in a patient with a leg ulcer?

A

if it is suspected that chronic osteomyelitis is underlying the ulcer

72
Q

What are the lifestyle related factors involved in the management of leg ulcers?

A
  1. stop smoking
  2. avoid trauma to the legs
  3. moderate regular exercise
  4. avoid obesity
  5. elevate legs
73
Q

What are the medical factors involved in the management of leg ulcers?

A
  1. treat lower limb oedema and prevent chronic venous hypertension
  2. analgesia
74
Q

How can healing of a leg ulcer be encouraged?

A
  1. correct dressing choice

2. use of topical treatments

75
Q

What are the 3 techniques to debride necrotic material in a leg ulcer?

A

Removing slough/dead tissue through:

  1. chemical debridement
  2. manual debridement
  3. surgical debridement

Y2 MECHANISMS OF DISEASE (36 decks)

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