Limb Ulceration

Question 1

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

Question 2

What are the four common types of skin ulcers? [4]

Answer 2

There are four common types of skin ulcers:

• Venous ulcers
• Arterial ulcers
• Diabetic foot ulcers
• Pressure ulcers

Question 3

The majority of lower limb ulcers are

Venous ulcers
Arterial ulcers
Diabetic foot ulcers
Pressure ulcers

Answer 3

The majority of lower limb ulcers are

Venous ulcers
Arterial ulcers
Diabetic foot ulcers
Pressure ulcers

Question 4

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

Answer 4

Iliofemoral DVT

Question 5

What is the difference in cause of arterial and venous ulcers? [2]

Answer 5

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.

Question 6

What is a common complication of diabetic foot ulcers? [1]

Answer 6

Osteomyelitis (infection in the bone)

Question 7

What features of an ulcer would indicate that its an arterial ulcer? [+]

Answer 7

• 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)

Question 8

Venous ulcers typically occur in which areas of the body? [1]

Answer 8

Occur in the gaiter area (between the top of the foot and bottom of the calf muscle)

Question 9

Arterial ulcers typically occur in which areas of the body? [1]

Answer 9

Occur distally, affecting the toes or dorsum of the foot

Question 10

Venous ulcers are associated with chronic venous changes, that can occur from which diseases? [3]

Answer 10

Are associated with chronic venous changes, such as hyperpigmentation, venous eczema and lipodermatosclerosis

Question 11

Which is more likely to bleed:

Arterial ulcer
Venous ulcer

Answer 11

Which is more likely to bleed:

Arterial ulcer
Venous ulcer

Question 12

Which is more likely to be painful:

Arterial ulcer
Venous ulcer

Answer 12

Which is more likely to be painful:

Arterial ulcer
Venous ulcer

Question 13

Which is more likely to be more painful when elevated?

Arterial ulcer
Venous ulcer

Answer 13

Which is more likely to be more painful when elevated?

Arterial ulcer
Venous ulcer

Question 14

Describe the investigations undertaken when assessing ulcers [4]

Answer 14

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.

Question 15

What would indicate a skin biopsy in leg ulcer? [1]

Answer 15

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.

Question 16

Describe how you would manage venous ulcers [4]

Answer 16

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)

Question 17

[] (taken orally) can improve healing in venous ulcers (but is not licensed).

Answer 17

Pentoxifylline (taken orally) can improve healing in venous ulcers (but is not licensed).

Question 18

Describe analgesia given in ulcers [1]

Answer 18

Analgesia is used to manage pain (avoid NSAIDs as they can worsen the condition).

Question 19

What score is used to screen for patients who are at risk of developing pressure areas [1]

Answer 19

The Waterlow score:
- includes a number of factors including body mass index, nutritional status, skin type, mobility and continence.

Question 20

Describe the conservative management for venous leg ulcers [3]

Answer 20

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

Question 21

Describe how to manage venous leg ulcers if conservative management doesn’t work? [1]

What must the ABPI be to initiate ^? [1]

Answer 21

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.

Question 22

Describe the management options for venous ulcers with concurrent varicose veins [2]

Answer 22

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.

Question 23

What antibiotic is commonly started for infected arterial ulcers, due to good coverage of Gram positive bacteria

Flucloxacillin

Gentamicin

Metronidazole

Fluconazole

Answer 23

What antibiotic is commonly started for infected arterial ulcers, due to good coverage of Gram positive bacteria

Flucloxacillin

Gentamicin

Metronidazole

Fluconazole

Question 24

A patient with a suspected arterial ulcer is likely to give a preceding history of? [2]

Answer 24

intermittent claudication (pain when they walk)

critical limb ischaemia (pain at night).

Question 25

Neuropathic ulcers can develop with any condition with peripheral neuropathy, the most common being **[2]**

Answer 25

Neuropathic ulcers can develop with any condition with peripheral neuropathy, the most common being **diabetes mellitus and B12 deficiency.**

Question 27

Describe the therapy options for PAD? [6]

Answer 27

**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)

Question 28

Describe the surgical treament options for PAD [3]

Answer 28

**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}

Question 29

How do you manage acute limb ischaemia? [6]

Answer 29

**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

Question 30

Which test is used to assess PAD in the leg? [1]

Answer 30

**Buerger’s test**

Question 31

Describe how Buerger's test is used to assess PAD in the leg [2]

Answer 31

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 colou**r. 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

Question 32

An ABPI above 1.3 can indicate [] of the arteries, making them difficult to compress. This is more common in diabetic patients.

Answer 32

**Calcification**

Question 33

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

Answer 33

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

Question 34

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

Answer 34

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

Question 35

What doses of atorvastatin and clopidogrel should be prescribed for PAD? [2]

Answer 35

**Atorvastatin 80 mg** **Clopidogrel 80 mg**

Question 36

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

Answer 36

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

Question 37

Peripheral arterial disease: - Buttock pain would indicate claudification in which vessel? [1] - Calf pain would indicate claudification in which vessel? [1]

Answer 37

Buttock pain: **internal iliac artery** Calf pain: **femoral vessels**

Question 38

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

Answer 38

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**

Question 39

How do you determine if CLI is treated with open surgical revasc or angioplasty & stent? [1]

Answer 39

Multifocal: **open revasc** Focal stenosis or thrombus: **angioplasty and stenting**

Question 40

Which differential diagnosis is key to rule out with AAA? [1]

Answer 40

Renal colic

Question 41

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

Answer 41

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

Question 42

You investigate a patient who is demonstrating stenosis. How do you determine if this patient needs open surgery or endovascular revascularization? [2]

Answer 42

Open surgery: long segments (> 10 cm) Endovascular: short segments ( < 10 cm)

Question 43

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]

Answer 43

Open surgery: **lesions of common femoral artery and infrapopliteal disease** Endovascular: short segments: **aortic iliac disease**

Question 44

You're investigating a skin lesion and think it might be squamous cel carcinoma of the skin. How would you tell? [1]

Answer 44

Looks like margarita pizza