Ulcers Flashcards
Where is a venous ulcer most commonly found
Lower third of the medial aspect of the leg, immediately above the medial malleolus (gaiter area)
What shape are venous ulcers usually
Size varies
Can be extremely large
Usually shallow
What does the edge of a venous ulcer look like
Sloping
Pale purple/brown in colour
What does the base of a venous ulcer look like
Covered with pink granulation tissue
May be some white fibrous tissue
Often have seropurulent discharge
What will the surrounding skin of a venous ulcer be like
Signs of chronic venous insufficiency
Temperature is warmer than the rest of the leg
What are the causes of venous ulcers
Valvular disease:-
Varicose veins
Deep vein reflux (such as post-DVT)
Communicating vein reflux (post-thrombotic or non-thrombotic)
Outflow tract obstruction:-
Often post-DVT
Muscle pump failure:-
Primary - stroke, neuromuscular disease
Secondary - due to musculoskeletal pathology/injury of the ankle
What is the non-surgical management of venous ulcers
Patient told to avoid trauma to affected area
Four-layer compression bandaging
Rest and elevation of leg
Grade II compression stockings for life once ulcer heals
What are the four layers of four layer compression bandaging
Non-adherent dressing over ulcer plus wool bandage
Crepe bandage
Blue-line bandage
Adhesive bandage to prevent other layers from slipping
What is the prognosis of venous ulcers
50-70% heal at 3 months
80-90% heal at 12 months
What is the next step if the ulcer fails to heal
Consider excluding other causes (eg. malignant ulcer)
Area may need to biopsied
*2% of chronic leg ulcers are malignant
What is the surgical management of venous ulcers
Split skin graft - excision of the dead skin and graft attached to healthy granulation tissue
Surgery to superficial varicose veins if they are the cause
Where are ischaemic ulcers usually found
Over the tips of the toes
Over pressure areas
What is the shape of an ischaemic ulcer
Size varies from few mm (tips of toes) to several cm (over lower leg)
What does the edge of an ischaemic ulcer look like
Punched out - no partial healing of wound
What does the base of an ischaemic ulcer look like
May contain slough
May be infected - no healthy red granulation tissue as blood supply too poor
May be very deep and penetrate down to bone with some bone exposed at base
What is the skin surrounding an ischaemic ulcer like
Grey/blue colour
Cold compared with the other foot
What are the causes of ischaemic ulcers
Large vessel arterial disease:-
Atherosclerosis
Thromboangiitis obliterans
Small vessel arterial disease:-
Diabetes mellitus
Polyarteritis nodosa
RA
What non-surgical management is available for ischaemic ulcers
Modify risk factors:-
Smoking cessation
Good diabetic and hypertensive control
Optimized serum lipid levels
Symptom modification:-
Analgesia- WHO ladder
Avoidance of drugs which might worsen symptoms (eg. beta blockers)
Low-dose aspirin - reduces incidence of CV events
IV prostaglandins
Lumbar sympathectomy: L1-L4
How do IV prostaglandins work in the management of ischaemic ulcers
Inhibit platelet aggregation
Stabilizing leukocytes and endothelial cells
Vasodilators
Have some effect in healing ulcers, relieving rest pain and reducing risk of amputation
How does lumbar sympathectomy work in the management of ischaemic ulcers
Reduces sympathetic-mediated vasoconstriction
Improves perfusion - allowing unopposed dilatation of skin vessels
*Often unsuccessful in diabetics (due to autonomic neuropathy)
What factors do you need to consider when describing ulcers?
Site Shape Size Surrounding skin Skin temperature Base Edge Pulses
Why do diabetics get ulcers?
Have a combination of: PVD- large vessel atherosclerosis Small vessel disease- affecting feet Neuropathy- don't notice injury Susceptible to infections- commonly synergistic anaerobic and aerobic infection --> gas gangrene up foot within 24 hours (drain asap! Reconstruct foot later)
When would you do a trans-metatarsal amputation?
In patients who have a good blood supply down to feet but have ischaemic toes.
Usually diabetics with small vessel disease
When examining ulcers, what do you look at?
3 BEDS
3S:
Site
Size
Shape
B-Base
E: Edge
D: Discharge
S: Surroundings (includes LNs and excoriation)
What is the most common type of ulcer?
Venous- 75%
Then mixed arteriovenous- 15%
Where are neuropathic ulcers found?
Pressure areas
Classically between toes, base of 1st and 5th metatarsals and heel
What size are neuropathic ulcers?
Variable
What shape are neuropathic ulcers?
Corresponds to shape of pressure point
What is the base of neuropathic ulcers like?
May be deep with bone exposed
What is the edge of neuropathic ulcers like?
Punched out
What are the surroundings of a neuropathic ulcer like?
Skin- looks normal Charcot's joints PVD signs if concomitant arterial disease Absent sensation around ulcer Absent ankle jerks
What are the temperature and peripheral pulses like in neuropathic ulcers?
Normal
Present
What are the causes of neuropathic ulcers?
Any cause of peripheral neuropathy: DM, ETOH, B12
Every vasculitis
What is the pathophysiology of neuropathic ulcers?
Sensory neuropathy: –> distal limb damage not felt by patient
Motor neuropathy: –> Wasting intrinsic foot muscles, altered foot shape (claw toes)
Autonomic neuropathy: Reduced sweating –> dry cracked foot
