Lower Leg Ulcers

Question 1

Venous leg ulcers

Answer 1

Most due to venous hypertension, secondary to chronic venous insufficiency, calf pump dysfunction or neuromuscular disorders
Ulcers form due to capillary fibrin cuff or leucocyte sequestration
Features of venous insufficiency include oedema, brown pigmentation, lipodermatosclerosis, eczema
Location above the ankle, painless
Deep venous insufficiency is related to previous DVT and superficial venous insufficiency is associated with varicose veins
Doppler ultrasound looks for presence of reflux and duplex ultrasound looks at the anatomy/ flow of the vein
Management - 4 layer compression banding after exclusion of arterial disease or surgery; if fail to heal after 12 weeks or >10cm2 skin grafting may be needed

Question 2

Marjolin’s ulcer

Answer 2

Squamous cell carcinoma
Occurring at sites of chronic inflammation e.g; burns, osteomyelitis after 10-20 years
Mainly occur on the lower limb
If, after many years, an ulcer becomes heaped up and irregular, with rolled edges then suspect a squamous cell carcinoma

Question 3

Arterial ulcers

Answer 3

Occur on the toes and heel
Painful
There may be areas of gangrene
Cold with no palpable pulses
Low ABPI measurements

Question 4

Neuropathic ulcers

Answer 4

Commonly over plantar surface of metatarsal head and plantar surface of hallux
The plantar neuropathic ulcer is the condition that most commonly leads to amputation in diabetic patients
Due to pressure
Management includes cushioned shoes to reduce callus formation

Question 5

Pyoderma gangrenosum

Answer 5

Associated with inflammatory bowel disease/RA
Can occur at stoma sites
Erythematous nodules or pustules which ulcerate