Limb Ulceration Flashcards
Limb Ulceration
* Learn the causes of chronic leg ulcers and describe the different appearances
* Learn how to differentiate venous and arterial leg ulcers
* Learn the pathogenesis of ischaemic, venous, pressure and diabetic ulcers
* Learn about the primary and secondary prevention of leg ulcers
* Learn about investigations indicated in leg ulcers and explain how these will help with patient management Learn the principles of management of chronic leg ulcers
* Learn the role of the multidisciplinary team in the prevention of pressure sores
What are the four common types of skin ulcers? [4]
There are four common types of skin ulcers:
- Venous ulcers
- Arterial ulcers
- Diabetic foot ulcers
- Pressure ulcers
The majority of lower limb ulcers are
Venous ulcers
Arterial ulcers
Diabetic foot ulcers
Pressure ulcers
The majority of lower limb ulcers are
Venous ulcers
Arterial ulcers
Diabetic foot ulcers
Pressure ulcers
In a patient presenting with an acutely swollen limb up to the thigh, what is the most likely diagnosis?
Joint infection
Sciatica
Acute embolic event
Iliofemoral DVT
Iliofemoral DVT
What is the difference in cause of arterial and venous ulcers? [2]
Arterial ulcers
- result from insufficient blood supply to the skin due to peripheral arterial disease.
Venous ulcers:
- occur due to the pooling of blood and waste products in the skin secondary to venous insufficiency.
What is a common complication of diabetic foot ulcers? [1]
Osteomyelitis (infection in the bone)
What features of an ulcer would indicate that its an arterial ulcer? [+]
- Occur distally, affecting the toes or dorsum of the foot
- Are associated with peripheral arterial disease, with absent pulses, pallor and intermittent claudication
- Are smaller than venous ulcers
- Are deeper than venous ulcers
- Have well defined borders
- Have a “punched-out” appearance
- Are pale colour due to poor blood supply
- Are less likely to bleed
- Are painful
- Have pain worse at night (when lying horizontally)
- Have pain is worse on elevating and improved by lowering the leg (gravity helps the circulation)
Venous ulcers typically occur in which areas of the body? [1]
Occur in the gaiter area (between the top of the foot and bottom of the calf muscle)
Arterial ulcers typically occur in which areas of the body? [1]
Occur distally, affecting the toes or dorsum of the foot
Venous ulcers are associated with chronic venous changes, that can occur from which diseases? [3]
Are associated with chronic venous changes, such as hyperpigmentation, venous eczema and lipodermatosclerosis
Which is more likely to bleed:
Arterial ulcer
Venous ulcer
Which is more likely to bleed:
Arterial ulcer
Venous ulcer
Which is more likely to be painful:
Arterial ulcer
Venous ulcer
Which is more likely to be painful:
Arterial ulcer
Venous ulcer
Which is more likely to be more painful when elevated?
Arterial ulcer
Venous ulcer
Which is more likely to be more painful when elevated?
Arterial ulcer
Venous ulcer
Describe the investigations undertaken when assessing ulcers [4]
Ankle-brachial pressure index (ABPI)
- is used to assess for arterial disease. This is required in both arterial and venous ulcers.
Duplex Ultrasound
Blood tests:
- infection (FBC and CRP)
- co-morbidities (HbA1c for diabetes
- FBC for anaemia
- albumin for malnutrition
Charcoal swabs
- may be helpful where infection is suspected, to determine the causative organism.
What would indicate a skin biopsy in leg ulcer? [1]
Skin biopsy may be required in patients where skin cancer (e.g., squamous cell carcinoma) is suspected as a differential diagnosis. This will require a two week wait referral to dermatology.
Describe how you would manage venous ulcers [4]
Vascular surgery where mixed or arterial ulcers are suspected
Tissue viability / specialist leg ulcer clinics in complex or non-healing ulcers
Dermatology where an alternative diagnosis is suspected, such as skin cancer
Pain clinics if the pain is difficult to manage
Diabetic ulcer services (for patients with diabetic ulcers)
[] (taken orally) can improve healing in venous ulcers (but is not licensed).
Pentoxifylline (taken orally) can improve healing in venous ulcers (but is not licensed).
Describe analgesia given in ulcers [1]
Analgesia is used to manage pain (avoid NSAIDs as they can worsen the condition).
What score is used to screen for patients who are at risk of developing pressure areas [1]
The Waterlow score:
- includes a number of factors including body mass index, nutritional status, skin type, mobility and continence.
Describe the conservative management for venous leg ulcers [3]
Conservative management for venous ulcers warrants:
- leg elevation
- increased exercise (promoting the calf muscle pump action which aids venous return)
- weight reduction and improved nutrition
Describe how to manage venous leg ulcers if conservative management doesn’t work? [1]
What must the ABPI be to initiate ^? [1]
Multicomponent compression bandaging, changed once or twice every week
ABPI must be measured as at least greater than 0.6 before any bandaging is applied.
30-75% of venous leg ulcers will heal after six months of compression therapy.
Describe the management options for venous ulcers with concurrent varicose veins [2]
If there is concurrent varicose veins, these should be treated with endovenous techniques or open surgery
improving venous return will allow for the healing of the venous ulcers.
What antibiotic is commonly started for infected arterial ulcers, due to good coverage of Gram positive bacteria
Flucloxacillin
Gentamicin
Metronidazole
Fluconazole
What antibiotic is commonly started for infected arterial ulcers, due to good coverage of Gram positive bacteria
Flucloxacillin
Gentamicin
Metronidazole
Fluconazole
A patient with a suspected arterial ulcer is likely to give a preceding history of? [2]
intermittent claudication (pain when they walk)
critical limb ischaemia (pain at night).
Neuropathic ulcers can develop with any condition with peripheral neuropathy, the most common being [2]
Neuropathic ulcers can develop with any condition with peripheral neuropathy, the most common being diabetes mellitus and B12 deficiency.
Describe the therapy options for PAD? [6]
Diabetic control:
- Reduce HbA1C by 1-2%
Cholesterol control:
- Artovastatin 80mg (all patients)
- Simvastatin 40mg
BP control
Antiplatets:
- Clopidogrel - 1st line
- Aspirin
Anti-oxidants & vitamins
Management of claudification:
- supervised exercise programmes: reduce symptoms by improving collateral blood flow. exercise till point of pain
- Vasoactive drugs:
Naftidrofuryl oxalate (5-HT2 receptor antagonist that acts as a peripheral vasodilator)
Describe the surgical treament options for PAD [3]
Angioplasty:
- inserting a catheter through the arterial system under x-ray guidance
- at the site of the stenosis, a balloon is inflated to create space in the lumen. A stent is can be ( but not always) inserted to keep the artery open
Endarterectomy
- cutting the vessel open and removing the atheromatous plaque
Bypass surgery
- using a graft to bypass the blockage
- may have to remove valve in a vein
- can use prosthetic graft if needed (Goretex / PTFE)
- veins last longer that prosthetic grafts}
How do you manage acute limb ischaemia? [6]
Acute emergency!
Endovascular thrombolysis:
- inserting a catheter through the arterial system to apply thrombolysis directly into the clot
Endovascular thrombectomy:
- inserting a catheter through the arterial system and removing the thrombus by aspiration or mechanical devices
Surgical thrombectomy
- cutting open the vessel and removing the thrombus
Endarterectomy
Bypass surgery
Amputation of the limb if it is not possible to restore the blood supply
Which test is used to assess PAD in the leg? [1]
Buerger’s test
Describe how Buerger’s test is used to assess PAD in the leg [2]
Two parts:
1. Part One
- lie patient on their back (supine).
- Lift the patient’s legs to an angle of 45 degrees at the hip.
- Hold them there for 1-2 minutes, looking for pallor.
- Pallor indicates the arterial supply is not adequate to overcome gravity, suggesting peripheral arterial disease.
- Buerger’s angle refers to the angle at which the leg is pale due to inadequate blood supply. For example, a Buerger’s angle of 30 degrees means that the legs go pale when lifted to 30 degrees.
2. Second Part
- The second part involves sitting the patient up with their legs hanging over the side of the bed. Blood will flow back into the legs assisted by gravity. In a healthy patient, the legs will remain a normal pink colour. In a patient with peripheral arterial disease, they will go:
* Blue initially, as the ischaemic tissue deoxygenates the blood
* Dark red after a short time, due to vasodilation in response to the waste products of anaerobic respiration
An ABPI above 1.3 can indicate [] of the arteries, making them difficult to compress. This is more common in diabetic patients.
Calcification
The severity of the aortic aneurysm depends on the size.
The severity of the aortic aneurysm depends on the size:
Normal: less than [] cm
Small aneurysm: [] – [] cm
Medium aneurysm: [] – [] cm
Large aneurysm: above [] cm
The severity of the aortic aneurysm depends on the size:
Normal: less than 3cm
Small aneurysm: 3 – 4.4cm
Medium aneurysm: 4.5 – 5.4cm
Large aneurysm: above 5.5cm
A 66-year-old man reports that he is struggling to walk his dog as he finds that his calves are intensely painful after about 10 mins. A lower limb examination is normal aside from absent posterior tibial and dorsalis pedis pulses. His past medical history includes a myocardial infarction 3 years ago and he also smokes 30/day.
Given the likely diagnosis, which one of the following medications should he be prescribed daily for secondary prevention of cardiovascular disease?
Clopidogrel 300mg
Atorvastatin 40mg
Clopidogrel 80mg
Simvastatin 20mg
Aspirin 300mg
A 66-year-old man reports that he is struggling to walk his dog as he finds that his calves are intensely painful after about 10 mins. A lower limb examination is normal aside from absent posterior tibial and dorsalis pedis pulses. His past medical history includes a myocardial infarction 3 years ago and he also smokes 30/day.
Given the likely diagnosis, which one of the following medications should he be prescribed daily for secondary prevention of cardiovascular disease?
Clopidogrel 300mg
Atorvastatin 40mg
Clopidogrel 80mg
Simvastatin 20mg
Aspirin 300mg
What doses of atorvastatin and clopidogrel should be prescribed for PAD? [2]
Atorvastatin 80 mg
Clopidogrel 80 mg
A 55-year-old lady with claudication is assessed and an ABPI is performed. Results show an ABPI value of 1.3. Which of the following conditions may lead to this abnormal result?
Hypothyroidism
Hypercalcaemia
Type 2 diabetes
Peripheral arterial disease
Previous deep vein thrombosis
A 55-year-old lady with claudication is assessed and an ABPI is performed. Results show an ABPI value of 1.3. Which of the following conditions may lead to this abnormal result?
Hypothyroidism
Hypercalcaemia
Type 2 diabetes
Peripheral arterial disease
Previous deep vein thrombosis
Peripheral arterial disease:
- Buttock pain would indicate claudification in which vessel? [1]
- Calf pain would indicate claudification in which vessel? [1]
Buttock pain: internal iliac artery
Calf pain: femoral vessels
A 38-year-old patient with known peripheral vascular disease presents to the emergency department complaining of pain at rest in his left leg. He is a smoker, however his BMI is 25 kg/m² and he has no other medical history.
On examination, he has absent foot pulses and lower limb pallor.
Critical limb ischaemia is suspected and he undergoes a CT angiogram which reveals a long segmental obstruction.
What is the most appropriate treatment?
Angioplasty with stenting
Aspirin
Balloon angioplasty
Below-knee amputation
Open bypass graft
A 38-year-old patient with known peripheral vascular disease presents to the emergency department complaining of pain at rest in his left leg. He is a smoker, however his BMI is 25 kg/m² and he has no other medical history.
On examination, he has absent foot pulses and lower limb pallor.
Critical limb ischaemia is suspected and he undergoes a CT angiogram which reveals a long segmental obstruction.
What is the most appropriate treatment?
Angioplasty with stenting
Aspirin
Balloon angioplasty
Below-knee amputation
Open bypass graft
How do you determine if CLI is treated with open surgical revasc or angioplasty & stent? [1]
Multifocal: open revasc
Focal stenosis or thrombus: angioplasty and stenting
Which differential diagnosis is key to rule out with AAA? [1]
Renal colic
A 35-year-old man has a 3-week history of progressive pain in his left calf. The pain is worse with activity, present at rest, but relieved by hanging his legs over the bedside. He has a medical history of hypertension and diabetes mellitus.
On examination, the left calf is paler than the right, and pulses are difficult to palpate. A small ulcer is noted on the dorsum aspect of the left foot. The right calf is unaffected. Magnetic resonance angiography demonstrates a stenotic lesion 8 cm in length in the femoral artery.
What is the most appropriate definitive management for this condition?
Endovascular revascularization
Femoral artery bypass surgery
Femoral endarterectomy
IV unfractionated heparin
Left lower limb amputation
A 35-year-old man has a 3-week history of progressive pain in his left calf. The pain is worse with activity, present at rest, but relieved by hanging his legs over the bedside. He has a medical history of hypertension and diabetes mellitus.
On examination, the left calf is paler than the right, and pulses are difficult to palpate. A small ulcer is noted on the dorsum aspect of the left foot. The right calf is unaffected. Magnetic resonance angiography demonstrates a stenotic lesion 8 cm in length in the femoral artery.
What is the most appropriate definitive management for this condition?
Endovascular revascularization
Peripheral arterial disease with critical limb ischaemia: high-risk patients with short segment stenosis are more suited to endovascular revascularization
You investigate a patient who is demonstrating stenosis. How do you determine if this patient needs open surgery or endovascular revascularization? [2]
Open surgery: long segments (> 10 cm)
Endovascular: short segments ( < 10 cm)
You investigate a patient who is demonstrating signs of CLI.
How do you determine from the vessel affected if this patient needs open surgery or endovascular revascularization? [2]
Open surgery: lesions of common femoral artery and infrapopliteal disease
Endovascular: short segments: aortic iliac disease
You’re investigating a skin lesion and think it might be squamous cel carcinoma of the skin.
How would you tell? [1]
Looks like margarita pizza
