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 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
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
