Leg ulcers

Question 1

what is a leg ulcer

Answer 1

full thickness skin loss on the leg or foot

Question 2

what are acute ulcers

Answer 2

may occur after trauma or surgery, normally heal within 4 weeks

Question 3

what is a chronic ulcer?

Answer 3

ulcer lasting >4 weeks

Question 4

commonest underlying causes of chronic ulcer?

Answer 4

venous and/ or arterial disease, neuropathy and diabetes

Question 5

most common type of leg ulcer?

Answer 5

venous (70-80%)

aka stasis ulcer

Question 6

12-20% of leg ulcers are ___

Answer 6

mixed (arterial and venous)

Question 7

aetiology of venous ulcers?

Answer 7

multifactorial

• venous insufficiency
• high venous pressure
• oedema within the surrounding tissue

Question 8

risk factors

Answer 8

• elderly age
• varicose veins
• previous DVT
• phlebitis
• immobility
• obesity

Question 9

pathophysiology of venous ulcers?

Answer 9

poor functioning of one-way valves in veins of lower legs > venous stasis and pooling > venous HTN > leakage of fluid from the venous vessels into the surrounding tissue causes oedema which contributes to lipodermatosclerosis > slows venous flow further, depriving area of oxygen and nutrients > tissue cells become necrotic and die > ulceration with poor healing

Question 10

what is lipodermatosclerosis?

Answer 10

involves tissue induration, deposition of haemosiderin, fibrosis and atrophy blanche

Question 11

venous ulcers

1) onset
2) location
3) appearance
4) symptoms/ signs

Answer 11

1) insidious
2) ‘gaiter’ region: from mid-calf to just below the malleoli
3) large circumference with irregular border, shallow ulcer, base has granulating tissue. Associated signs of venous disease: varicose veins, venous eczema, stasis dermatitis, hyperpigmentation (haemosiderin deposition)
4) little/ no pain (relieved by elevation). Lipodermatosclerosis. Atrophe blanche

Question 12

what is atrophe blanche

Answer 12

Telangiectasia appears where there are areas of venous congestion. When the capillaries can no longer cope with this high pressure they collapse, resulting in white areas of avascular tissue.

Question 13

T/F: diagnosis of venous leg ulcers is usually clinical

Answer 13

true

should also investigate for any underlying cause (usually only found if arterial/ mixed) - diabetes, vasculitis, RA etc

Question 14

ABPI values?

Answer 14

0.9-1.2 = Normal.
0.8-0.9 = Mild arterial disease.
0.5-0.8 = Moderate
<0.5 = Severe (refer urgently to vascular surgery)

Question 15

what Ix to do if ulcer is mixed?

Answer 15

doppler USS

Question 16

when to swab an ulcer?

if +ve should you treat with Abx?

Answer 16

if painful, growing, malodorous, exudate

swabs often grow commensals- only treat if infected clinically

Question 17

Rx of venous ulcers?

Answer 17

• pain control
• underlying cause
• non-adherent dressings
• de-sloughing agent
• compression bandaging (4 layers)

Question 18

purpose of non-adherent dressings in venous ulcers?

Answer 18

helps create optimum environment for ulcer healing (pH, temp, anti-microbial)

Question 19

examples of de-sloughing agents?

Answer 19

honey, hydrogel

Question 20

how does doppler US help guide compression bandaging treatment for venous ulcers?

Answer 20

Doppler score >0.8 = Graduated compression bandage.
Score 0.5-0.8 = Reduced / light compression bandage.
Score <0.5 = Compression bandage contraindicated.

Question 21

what causes an arterial leg ulcer?

Answer 21

reduced blood flow within the lower leg, most commonly due to atherosclerosis

Question 22

risk factors for arterial ulcers?

Answer 22

IHD
Previous CVA or TIA
Diabetes mellitus
Peripheral vascular disease
Obesity
Immobility
Hypertension
Smoking

Question 23

how do arterial leg ulcers form?

Answer 23

atherosclerosis > narrowing of lower leg arteries > thickening of arterial walls mean nutrients and oxygen within blood can’t be sufficiently delivered to the tissues > cell necrosis and tissue breakdown

Question 24

arterial ulcers are typically located more PROXIMALLY/ DISTALLY in lower leg

Answer 24

distally (dorsum of foot/ toes)

Question 25

Arterial ulcers

1) edges?
2) depth?
3) colour?
4) T/F: palpation of ulcer will cause significant bleeding
5) painful?
6) other features?

Answer 25

1) irregular at first, become more clearly defined ‘punched out’ appearance
2) smaller and deeper than venous
3) grey coloured granulation tissue at base of ulcer
4) false
5) pain typically nocturnal, most when patient is supine, relieved by dangling legs over edge of bed
6) features of chronic peripheral vascular disease: hairlessess, white/ pale skin, absent peripheral pulses, nail dystrophy, wasting/ atrophy of lower limb muscles

Question 26

Rx of arterial ulcers?

Answer 26

similar to management of peripheral vascular disease
- control pain
- underlying cause
- non-adherence dressings
- de-sloughing agent
- referral to vascular surgery
NB: compression bandaging usually contraindicated but light compression may be possible with mixed ulcers where ABPI >0.5