Leg Ulcers

Question 1

What is an ulcer?

Answer 1

Discontinuity of surface epithelium

Question 2

What are features of leg ulcers?

Answer 2

• Discontinuity of squamous epithelium of skin around ankle + foot
• Acute or chronic (>4-6wks)
• Usually co-infection w/ Staph Aureus, Strep Pyogenes + E. Coli

Question 3

What is the aetiology of leg ulcers?

Answer 3

• Venous disease (70%)
• Mixed (15%)
• Arterial disease (2%)

Others: neuropathy, vasculitis, malignancy, infection, trauma

Question 4

What are key features of venous leg ulcers?

Answer 4

• Mostly due to HTN 2^o to chronic venous insufficiency (deep or superficial)
• Deep related to DVT, superficial related to varicose veins
• Sx → oedema, brown pigmentation (hemosiderin), lipodermatosclerosis, eczema
• Location → medial malleolus, above ankle, painless
• RFs → VV, DVT, venous insufficiency, AV fistulae, obesity, fractures

Question 5

How is ABPI interpreted?

Answer 5

• > 1.2 → may indicate calcified, stiff arteries. This may be seen with advanced age or PAD
• 1.0 - 1.2 → normal
• 0.9 - 1.0 → acceptable
• < 0.9 → likely PAD. Values < 0.5 indicate severe disease which should be referred urgently

Question 6

Which investigations should be done for venous leg ulcer?

Answer 6

• ABPI to assess for arterial disease
• Doppler USS → presence of reflux
• Duplex USS → anatomy/flow of vein

Question 7

What is the management for venous leg ulcers?

Answer 7

• Charing cross 4-layer compression bandaging
• Skin grafting if fail to heal after 12wks or >10cm²

Question 8

What are features of arterial leg ulcers?

Answer 8

• Occur on toes and heel
• Painful, may be areas of gangrene
• Cold + no palpable pulses
• ABPI <0.9

Question 9

What is the treatment for aterial leg ulcers?

Answer 9

• Antiplatelet
• Statin
• Surgical revascularisation

Question 10

What are the features and management of neuropathic ulcers?

Answer 10

• Commonly over plantar surface of metatarsal head and plantar surface of hallux, due to pressure
• Plantar neuropathic ulcer most commonly leads to amputation in diabetic pts
• Rx → cushioned shoes to reduce callous formation

Question 11

What are features of pressure ulcers?

Answer 11

• Develop in pts unable to mobilise due to illness, age or paralysis
• Typically over bony prominences such as heel or sacrum
• RFs → malnutrition, incontinence, immobility, pain (less movement)

Question 12

What is the Waterlow score?

Answer 12

To screen for patients who are AT RISK of developing pressure sores

Question 13

How are pressure ulcers graded?

Answer 13

• European Pressure Ulcer Advisory Panel classification system

Question 14

What is the management of pressure ulcers?

Answer 14

• Pressure relieving mattresses + cushions
• Frequent repositioning
• Encourage moist wound environment w/ hydrocolloid dressings
• Discourage wound swabs as most are colonised
• Refer to tissue viability nurse
• Abx only if evidence of infection (surrounding cellulitis)

Question 15

What is Marjolin’s ulcer?

Answer 15

• Squamous cell carcinoma
• Occurring at sites of chronic inflammation eg. burns, osteomyelitis after 10-20 yrs
• Mainly occur on lower limb

Question 16

What is pyoderma gangrenosum?

Answer 16

• Associated w/ inflammatory bowel disease & rheumatoid arthritis
• Can occur at stoma sites
• Erythematous nodules or pustules which ulcerate