Leg ulcers Flashcards
define chronic leg ulceration
open wound between the knee and the ankle joint that remains unhealed for at least 4 weeks
causes of leg ulcers
vascular - venous, arterial, mixed
trauma
malignancy
infection
conditions associated with leg ulcers
diabetes
rheumatoid arthritis
most common type of leg ulcers
venous insufficiency
what leads to venous insufficiency and leg ulcers
valve incompetence
muscle pump insufficiency
results in stasis and pooling in the lower limbs which leads to oedema and lack of oxygen and nutrient supply to tissues
ultimately you get ischaemia, necrosis and ulcer development
holistic approach to a leg ulcer
identify the aetiology and reasons for poor healing
what should make up your general assessment of the patient with a leg ulcer
age obesity social circumstances nutrition mobility
RF for venous leg ulceration
DVT
varicose veins
fractures
surgery
RF for arterial leg ulceration
peripheral vascular disease
smoking
ischaemic heart disease
stroke
other conditions to ask about in the PMH
diabetes
thyroid disease
Rheumatoid arthritis
vasculitis
signs of venous ulceration
varicose veins
oedema
varicose eczema - bilateral, itchy, often 1st sign
haemosiderin staining - brown/red
lipodermatosclerosis - hardening and fibrosis of skin resulting in inverted champagne bottle appearance, hard and woody tethered skin
atrophie blanche - white scar like areas
signs of arterial ulceration
absent pulses cold pale punched out ulcer prolonged CRT hair loss
what should you look for on examination
location
appearance and depth
surrounding skin appearance
site, shape, depth of venous ulceration
site - medial malleolus / lower leg / gaiter area
shape - single, oval
depth - shallow, flat edge
can be painful
site, shape, depth of arterial ulceration
site - pressure points eg bony prominences
shape - variable, may be multiple
depth - deep, punched out, may expose underlying structures
skin - signs of impaired nutrition
pain - very painful, especially at night
clinical features of vasculitic ulcers
multiple lesions bilateral anywhere on calf multiple, small round lesions that coalesce, may show necrosis shallow usually painful
what is the most important investigation for leg ulceration
ABPI ankle brachial pressure index using a hand held doppler device
how do you calculate ABPI
highest brachial reading (L or R)
what do the following ABPI results mean: >0.8 0.6-0.8 <0.6 >1.2
> 0.8 - excludes significant arterial disease, suitable for compression
0.6-0.8 - suitable for reduced compression, further vascular assessment
<0.6 - no compression, refer to vascular surgeon
1.2 - calcification of arteries, reduced compression
what happens if you apply compression to a patients with impaired arterial circulation
necrosis of skin
other factors to consider in poor healing
anaemia diabetes renal and hepatic problems thyroid disease vasculitis skin cancer infection
what is the gold standard treatment for uncomplicated venous leg ulcers
graduated compression bandaging with pressures of 40mmHg at the ankle and 25mmHg below the knee
management of arterial leg ulcers
surgery
analgesia
avoid compression
management of vasculitic ulcers
treat underlying cause
what should be done at 12 weeks for leg ulcers
reassessment to check for healing
3 main complications of chronic leg ulcers
secondary infection
contact allergy
malignant transformation
if an ulcer looks bad, you should take a swab?
no, only if there are clinical signs of infection eg surrounding cellulitis, fever, increased exudate, offensive smell, deterioration of ulcer
what kind of cancer can chronic ulcers transform to
SCC
what is a Marjolin’s ulcer
name given to malignant transformation of chronic wounds
examples of leg ulcer prophylaxis
below knee graduated compression hosiery worn daily
leg ulcer recurrence is very high
how often should replacement stocking for ulcer prophylaxis be given
every 4-6 months
what is slough
skin debris and dead bacteria
