Leg ulcers - venous, arterial and diabetic Flashcards
1
Q
3 origins of ulcers
A
- Venous- majority
- Arterial insufficiency
- Diabetic neuropathy
- Can also get pressure ulcers
2
Q
Venous ulcers
A
- Shallow ulcers
- Granulated base
- Other features of venous insufficiency present eg varicose eczema, haemosiderin
- Classically medial malleolus
- Prone to infection - can present with cellulitis features
3
Q
Arterial ulcers
A
- Distant sites
- Well defined borders
- Other features of arterial insufficiency
4
Q
Neuropathic ulcers
A
- Painless ulcers
- Areas of abnormal pressure, plantar surface
- Secondary to joint deformities in diabetics
5
Q
Pathophysiology of venous ulcers
A
- Impaired venous return (valvular incompetence or venous outflow obstruction)
- Trapped WBC in capillaries
- Formation of fibrin cuff around vessel, hindering O2 delivery
- Release of inflammatory mediators
- = tissue injury, poor healing, necrosis
6
Q
Define ulcer
A
- Break in epithelial continuity
7
Q
RF for venous ulcer
A
- Increasing age
- Pre-existing venous incompetence/history of VTE (inc varicose veins)
- Pregnancy
- Obesity or physical inactivity
- Leg injury/trauma
8
Q
Anatomy of ulcer
A
9
Q
Classification of ulcers - edge
A
- SUPER
- Sloping edge - venous
- Undermined edge - TB/pressure sores
- Punched out edge - arterial, diabetes, syphilis
- Everted edge - SCC
- Raised edge - BCC
10
Q
Site of ulcers and common cause
A
- Medial malleolus - venous, varicose
- Upper part of face, above line joining mouth and ear - BCC/rodent ulcer
- Foot sole, great toe sole - diabetic ulcer, painless
- Digits of lower limbs - arterial
11
Q
Investigations for venous ulcer
A
- Duplex USS - looks for reflux and flow
- APBI to rule out arterial insuffienciency
12
Q
Management venous ulver
A
- Multicomponent pressure bandaging - changed every week
- Leg elevation, increased exercise, weight loss improved nutrition
- Use emoilients too
13
Q
Surgery for venous ulcers?
A
If varicose veins present - treat with endovenous techniques or open surgery
14
Q
RF for arterial ulcers
A
- PAD RF eg
- Smoking
- Diabetes mellitus
- HTN
- Hyperlipidaemia
- Increasing age
- Positive FH
- Physical inactivity
15
Q
Reasons for amputation (3D’s)
A
- Dead - dry gangrene, sometimes autoamputates
- Deadly - malignant tumours, sepsis
- Damn nuisance - retaining limb worse than keeping - eg severe loss function, malformation
16
Q
Management neuropathic ulcer
A
- Optimise diabetic control - good diet and exercise
- Regular chiropody - cushioned shoes, foot hygiene
- Diabetic foot clinics
- If infection - swab and start abx (flucloxacillin)
- Ischaemic or necrotic tissue will need debridement
17
Q
Clinical features of arterial ulcer
A
- History of intermittent claudication
- Develops over long period of time, no healing
- Painful
- Limbs cold with absent or weak pulses
- Shiny thin skin - less blood to skin = hair loss, atrophy easy to damage
18
Q
Investigations for arterial ulcer
A
- ABPI
- Imaging - duplex USS, CT angiograph MR angiogram
19
Q
Management arterial ulcer
A
- Vascular review
- Conservative - classic reduce RF
- Medical - statin, aspirin or clopidogrel, optimise BP and BMs
- Surgery - angioplasty +/- stent or bypass grafing
20
Q
Investigations for neuropathic ulcer
A
- Blood glucose levels - random or HbA1C
- B12 levels
- Infection - swab
- X-ray to assess osteomyelitis
- Assess neuropathy with 10g monofilament and 128Hz vibtration tuning fork
21
Q
Chronic/non-healing ulcer
A
- remains more than 6 weeks
- Not responding to management
22
Q
Charcot foot
A
- Seen alongside neuropathic ulcers
- Loss of joint sensation = continual unnoticed trauma and deformity
- Present with swelling and disortion
- Loss of transverse arch - rocker bottom foot
- Need immbolisation in plaster
23
Q
What is Marjolin ulcer
A
- Site of chronic inflamm - burns, osteomyelitis after 10-20 years
- Type of SCC
- Mainly lower limb
24
Q
What is pyoderma gangrenosum?
A
- Associated with IBD and RA
- Can occur at stoma sites
- Erythematous nodules or pustules which ulcerate
25
Q
A
