Limb Ulceration Flashcards
What are the causes of leg ulceration
- venous hypertension
- arterial disease
- neuropathic
- neoplastic
- vasculitis
- infection
- haematological
- drugs
- other
What are the different types of leg ulcers
- Venous ulcers
- arterial ulcers
- neuropathic ulcers
- pressure ulcers
- diabetic ulcers
- ischeaemic ulcers
What causes venous ulcers
- venous ulcers are the result of sustained venous hypertension in the superficial veins due to incompetent valves in the deep perforating veins or to previous deep vein thrombosis
What are venous ulcers associated with
- oedema of the lower legs
- venous eczema
- brown pigmentation from haemosiderin
- varicose veins
What is the management of venous ulcers
- high compression bandaging and leg elevation to reduce venous hypertension
- doppler studies should be done before compression to exclude significant arterial disease
- diuretics can reduce the oedema
- antibiotics only necessary for overt bacterial infection
- opiate pain medication if required
- ulcer dressings
Where are arterial ulcers
- present as punched out, painful ulcers higher up on the leg or on the feet
What is the clinical presentation of arterial ulcers
- clinically the leg is cold and pale
- absent peripheral pulse
- arterial bruits
- loss of hair
What is the management of arterial ulcers
- keep the ulcer clean and covered
- adequate analgesia and vascular reconstruction if appropriate
What causes neuropathic ulcers
- tend to be over pressure areas of the feet such as the metatarsal heads owing to repeated trauma
- most commonly found in diabetics due to peripheral neuropathy
what causes arterial ulcers (ischaemic ulcers)
Arterial leg ulcers occur as a result of reduced arterial blood flow and subsequent tissue perfusion.
Three mechanisms involved in the pathophysiology :
- (a) extramural strangulation,
- (b) mural thickening or accretion
- (c) intramural restriction of blood flow
What causes diabetic ulcers
Diabetic ulcers are most commonly caused by: poor circulation. high blood sugar (hyperglycemia) nerve damage
What is the management of pressure ulcers
- bed rest with pillows and fleeces to keep pressure of bony areas and to prevent friction
- air filled cushions for patients in wheelchairs
- special pressure relieving mattresses and beds
- regular turning but avoidance of pressure on hips
- adequate nutrition
- treatment of underlying cause
How can you prevent ulcers
- identify at risk patients
- use of the Norton scale to identify those who are most at risk
Primary prevention
- loose weight
- compression stockings
- treat underlying cause such as varicose veins
if the skin ulcer is superior to the medial malleolus what type of ulcer is it likely to be
- venous ulcer
If the skin ulcer is around the sacrum, greater trochanter, or heel what type of ulcer is it likely to be
- pressure sore (decubitus ulcer)
What does an ischaemic ulcer feel like
- ulcer and surrounding tissue are cold
When does an ulcer become a chronic ulcer
4 weeks old
What does the shape of the ulcer tell you about what has caused it
- Oval, circular → cigarette burn
- Serpiginous → Klebsiella granulomatis
- Unusual shape → mycobacterial infection (eg cutaneous TB or Scrofuloderma)
what does the edge of the ulcer tell you about it
- Shelved/sloping = healing
- punched out = syphilis or ischaemic
- Rolled/everted = malignant
What does the discharge tell you about the ulcer
- watery discharge = TB
- bleeding = malignancy
What does associated lymphadenopathy suggest
- suggests infection or malignancy
What does decreased sensation around the ulcer suggest
- implies neuropathy
What do arterial ulcers look like and what are they common in
- punched out appearance
- full thickness defect
- common in DM
- can occur anywhere in the extremities
What do venous ulcers look like and where are them
- accompanied by varicose veins
- distal leg and ankle
- painful and heavily exudative
- often recurrent
- exhibit varying depths even within 1 ulcer
- can become huge
where and why do pressure ulcers occur
- usually occur on bony prominences
- occur because pressure obstructs superficial blood flow
What is Marjolin’s ulcer
- Squamous cell carcinoma
- occurring at sites of chronic inflammation e.g. burns, osteomyelitis after 10-20 years
- mainly occur on the lower limb
where do neuropathic ulcers occur and why do they occur
- they commonly occur over plantar surface of metatarsal head and plantar surface of hallux
- plantar neuropathic ulcer is the condition that most commonly leads to amputation in diabetic patients
- due to pressure
- management includes cushioned shoes to reduce callous formation
What is pyoderma gangrenous associated with
- associated with inflammatory bowel disease
What does pyoderma gangrenosum look like and where does it occur
- can occur at stoma sites
- erythematous nodules or pustules which ulcerate
What investigations do you carry out of Ulcers
- note appearance
- ABPI - arterial or venous insufficiency
- biopsy - to assess for vasculitis and malignant changes
What is the management of ulcers
Treat cause and focus on prevention
Bandaging
- Charing Cross - 4 layer compression bandaging preferred (ABPI>0.8)
- Honey dressings for mild-moderate burns
- negative pressure wound therapy (VAC) for diabetic ulcers
Surgery, larval therapy, hydrogels
- used to debride sloughy necrotic tissue
Antibiotics
- only if infection - does not improve healing
