Lower Limb Ulcers

Question 1

Types of ulcer

Answer 1

Venous
Arterial
Pressure
Neuropathic

Question 2

Venous ulcer clinical features

Answer 2

Shallow ulcers with a granulated base

Irregular border

Painful

Normally on medial malleolus - gaiter area

Clinical features of venous insufficiency

Question 3

Neuropathic ulcer clinical features

Answer 3

Painless ulcers

Over areas of abnormal pressure

Punched out appearance

Often secondary to joint deformity in diabetics

May get:

• burning/tingling in legs (painful neuropathy)
• single nerve involvement (mononeuritis multiplex)
• amotrophic neuropathy (painful wasting of proximal quadriceps)

Question 4

Arterial ulcers clinical features

Answer 4

Small and deep

Distal sites

Well-defined borders with necrotic base

Painful and gradual development
Evidence of arterial insufficiency
- intermittent claudication 
- critical limb ischaemia
- cold limb 
- lack of pulses  
- limb hair loss

Question 5

Most common type of leg ulcer

Answer 5

Venous ulcer

Question 6

Complications of venous ulcers

Answer 6

Prone to infection and can present with associated cellulitis

Question 7

Risk factors for venous ulcers

Answer 7

Increasing age
Pre-existing venous incompetence or history of venous thromboembolism
- Including varicose veins
Pregnancy
Obesity or physical inactivity
Severe leg injury or trauma

Question 8

Clinical features of venous insufficiency

Answer 8

Aching
Itching or a bursting sensation

Varicose veins with ankle or leg oedema
Varicose eczema or thrombophlebitis
Haemosiderin skin staining
Lipodermatosclerosis
Atrophie blanche

Question 9

Investigations for venous ulcers

Answer 9

Clinical 
Vascular exam
Venous insufficiency - duplex USS
ABPI
Swab cultures

Question 10

Management of venous ulcers

Answer 10

Leg elevation 
Increased exercise 
Lifestyle changes:
- weight reduction 
- decreased fat intake 

abx - if wound infection

Multicomponent compression bandaging - changed once or twice every week

If varicose veins - endovenous techniques or open surgery

Question 11

How long does venous ulcers take to heal on average with compression

Answer 11

6 months

Question 12

ABPI before bandaging

Answer 12

At least greater than 0.6 before any bandaging is applied

Question 13

Risk factors for arterial ulcers

Answer 13

Peripheral arterial disease
Smoking
Diabetes mellitus
Hypertension
Hyperlipidaemia
Increasing age
Family history
Obesity and physical inactivity

Question 14

Investigations for arterial ulcers

Answer 14

Vascular examination

ABPI

Question 15

ABPI

Answer 15

> 1.3 = unreliable test 
>0.9 = normal
0.9-0.8 = mild
0.8-0.5 = moderate
<0.5 = severe

Question 16

Management of arterial ulcers

Answer 16

Conservative:
- lifestyle modification

Medical:

• CVS risk reduction - statin and aspirin
• optimise blood pressure and glucose

Surgery:

• Angioplasty with or without stenting
• Bypass graft

Question 17

Neuropathic ulcers cause

Answer 17

Peripheral neuropathy

- loss of sensation therefore injuries are unnoticed

Question 18

Investigations for neuropathic ulcers

Answer 18

Vascular examination
Peripheral neuropathy examination

Blood glucose levels
Serum B12 - glove and stocking paraesthesia

ABPI if arterial disease

Swab

Xray - osteomyelitis

Question 19

Mx of neuropathic ulcers

Answer 19

Diabetic foot clinics
Diabetic control - MOST IMPORTANT
Lifestyle modification
Regular foot checks

Abx if infection

Surgical debridement - necrotic tissue

Question 20

Causes of peripheral neuropathy

Answer 20

DM
Vit B12 deficiency
TB

Question 21

Investigations for neuropathic ulcers

Answer 21

Blood glucose
ABPI
Swabs
X-ray - osteomyelitis