Leg Ulcers Flashcards
What is an ulcer?
Break in skin or mucous membrane that fails to heal as it usually should
Ulcers can be both arterial and venous; true or false?
True “mixed ulcers”
Which accounts for the majority of lower limb ulcers; venous or arterial?
Venous (80%)
Other causes include arterial, diabetic neuropathy, trauma, vasculitis etc…
Describe the pathophysiology of venous ulcers
Occur due to pooling of blood and waste products in the skin secondary to impaired venous drainage. Impaired drainage leads to venous hypertension.
Their pathophysiology is poorly understood. It is thought that valvular incompetence or venous outflow obstruction leads to impaired venous return, with the resultant venous hypertension causing the “trapping” of white blood cells in capillaries and the formation of a fibrin cuff around the vessel hindering oxygen transportation into the tissue. The white blood cells subsequently become activated, with the release of inflammatory mediators leading to resultant tissue injury, poor healing, and necrosis.
Describe the typical presentation of venous ulcers- focus on:
- Appearance
- Associated symptoms & signs
- Shallow
- Irregular borders
- Granulating base
- Tend to be larger than arterial ulcers
- Pain relieved by elevation and worse on hanging
- More likely to bleed
- Features of venous insufficiency:
- Hyperpigmentation
- Oedema
- Varicose eczema
Where are venous ulcers most commonly found?
Gaiter region
State some risk factors for developing venous ulcers
Anything that increases risk of venous insufficiency:
- Increasing age
- Pregnany
- Obesity
- Physical inactivity
- Pre-exisiting venous insufficiency/incompetence
- Previous DVT
- Previous leg injury
Discuss what investigations are required for a venous ulcer
- Duplex ultrasound: confirm underlying venous insufficiency
- Swab & culture: if suspected infection
- ABPI: to assess for any arterial component to ulcer and determine if suitable for compression therapy
Discuss the management of venous ulcers, consider:
*
- Good wound care (debridement, cleaning, dressing)
-
Lifestyle:
- Increased exercise (promote calf muscle pump action)
- Weight loss
- Improved nutrition
- Leg elevation
- Multicomponent pressure bandaging
- Treat any associated varicose veins (treating this improves ucler healing)
- Abx if infected
Multicomponent compression bandages are the mainstay of treatment for venous uclers, discuss:
- How they work
- How often they should be changed
- How long takes for ulcers to heals
- Associated care required
- Compress leg to help with venous return
- Once or twice a week
- 30-75% heal within 6 months of compression bandages
- Must use appropriate dressings & emollients to maintain health of surrounding skin
What value must the ABPI be above if you wish to use 4-layer compression bandages for venous ulcers?
> 0.8
Describe the typical presentation of arterial ulcers, focus on:
- Appearance
- Symptoms & signs
- More regular borders
- Grey colour due to poor blood supply
- No or little granulation tissue
- Tend to be smaller than venous ulcers
- Less likely to bleed
- More painful than venous
- Pain at night when legs elevated
- Pain worse on elevating leg, improved by hanging
- Pallor
- Absent pulses
Described the pathophysiology of arterial uclers
Poor blood supply to skin due to peripheral arterial disease which means break in skin or mucous membrane cannot heal effectively resutling in ucler formation
State some risk factros for arterial ulcers
Anything that increases risk of peripheral arterial disease
- Smoking
- Hyperlipidaemia
- Hypercholesterolaemia
- Obesity
- Diabetes
- Hypertension
- ….
What investigations are required for arterial ulcers?
- ABPI
- Duplex ultrasound, CT angiography or MRA to determine location of arterial disease
Discuss the management of arterial uclers, include:
- Conservative
- Pharmacological
- Surgical
***Conservative & pharmacological same as for peripheral arterial disease
Conservative
- Lifestyle to reduce CVD risk e.g. stop smoking, exercise, weight loss, healthy diet, reduce alcohol, exercise rehabilitation etc..
- Good wound care (debridement, cleaning, dressing)
Pharmacological
- Optimise control of cormorbidities
- Statin= 80mg atorvastatin
- Antiplatelet= 75mg clopidogrel (or aspirin & dipyridamole)
- Naftidrofuryl oxalate
Surgical
- Angioplasty (with or without stenting)
- Bypass grafting (usually for more extensive disease).
- Any non-healing ulcers despite a good blood supply may also be offered skin reconstruction with grafts.
Describe how neuropathic ulcers form
Results from peripheral neuorpathy; loss of protective sensation which leads to repetitive stress and unnoticed injuries forming painless ulcers on pressure points on limb.
Neuropathic ulcers can develop in any condition with peripheral neuropathy but state the two most common causes
- Diabetes
- B12 deficiency
Describe the typical presentation of someone with a neuropathic ulcer
- History of peripheral neuropathy
- Uclers have punched out appearance
- Occur most commmonly on sites of pressure in feet
What investigations would you do for a neuropathic ulcer?
- Blood glucose
- HbA1c
- Serum B12
- ABPI
- Consider duplex ultrasound to assess for aterial component
- Consider microbiology swap if think infected
- Consider x-ray if concerned about osteomyelitis
Discuss the management of neuropathic ulcers
- Optimise diabetic control
- Ensure regular chiropody
- Abx if infection (flucloxacillin)
- Ischaemic or necrotic tissue may require surgical debridement or in severe cases necrotic or infected digits may need to be amputated
