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Vascular > Ulcers > Flashcards

Ulcers Flashcards

1
Q

Where is a venous ulcer most commonly found

A

Lower third of the medial aspect of the leg, immediately above the medial malleolus (gaiter area)

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2
Q

What shape are venous ulcers usually

A

Size varies
Can be extremely large
Usually shallow

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3
Q

What does the edge of a venous ulcer look like

A

Sloping

Pale purple/brown in colour

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4
Q

What does the base of a venous ulcer look like

A

Covered with pink granulation tissue
May be some white fibrous tissue
Often have seropurulent discharge

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5
Q

What will the surrounding skin of a venous ulcer be like

A

Signs of chronic venous insufficiency

Temperature is warmer than the rest of the leg

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6
Q

What are the causes of venous ulcers

A

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

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7
Q

What is the non-surgical management of venous ulcers

A

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

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8
Q

What are the four layers of four layer compression bandaging

A

Non-adherent dressing over ulcer plus wool bandage
Crepe bandage
Blue-line bandage
Adhesive bandage to prevent other layers from slipping

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9
Q

What is the prognosis of venous ulcers

A

50-70% heal at 3 months

80-90% heal at 12 months

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10
Q

What is the next step if the ulcer fails to heal

A

Consider excluding other causes (eg. malignant ulcer)
Area may need to biopsied

*2% of chronic leg ulcers are malignant

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11
Q

What is the surgical management of venous ulcers

A

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

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12
Q

Where are ischaemic ulcers usually found

A

Over the tips of the toes

Over pressure areas

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13
Q

What is the shape of an ischaemic ulcer

A

Size varies from few mm (tips of toes) to several cm (over lower leg)

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14
Q

What does the edge of an ischaemic ulcer look like

A

Punched out - no partial healing of wound

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15
Q

What does the base of an ischaemic ulcer look like

A

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

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16
Q

What is the skin surrounding an ischaemic ulcer like

A

Grey/blue colour

Cold compared with the other foot

17
Q

What are the causes of ischaemic ulcers

A

Large vessel arterial disease:-
Atherosclerosis
Thromboangiitis obliterans

Small vessel arterial disease:-
Diabetes mellitus
Polyarteritis nodosa
RA

18
Q

What non-surgical management is available for ischaemic ulcers

A

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

19
Q

How do IV prostaglandins work in the management of ischaemic ulcers

A

Inhibit platelet aggregation
Stabilizing leukocytes and endothelial cells
Vasodilators

Have some effect in healing ulcers, relieving rest pain and reducing risk of amputation

20
Q

How does lumbar sympathectomy work in the management of ischaemic ulcers

A

Reduces sympathetic-mediated vasoconstriction
Improves perfusion - allowing unopposed dilatation of skin vessels

*Often unsuccessful in diabetics (due to autonomic neuropathy)

21
Q

What factors do you need to consider when describing ulcers?

A 
Site
Shape
Size
Surrounding skin
Skin temperature
Base
Edge
Pulses
22
Q

Why do diabetics get ulcers?

A 
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)
23
Q

When would you do a trans-metatarsal amputation?

A

In patients who have a good blood supply down to feet but have ischaemic toes.

Usually diabetics with small vessel disease

24
Q

When examining ulcers, what do you look at?

A

3 BEDS

3S:
Site
Size
Shape

B-Base

E: Edge

D: Discharge

S: Surroundings (includes LNs and excoriation)

25
Q

What is the most common type of ulcer?

A

Venous- 75%

Then mixed arteriovenous- 15%

26
Q

Where are neuropathic ulcers found?

A

Pressure areas

Classically between toes, base of 1st and 5th metatarsals and heel

27
Q

What size are neuropathic ulcers?

A

Variable

28
Q

What shape are neuropathic ulcers?

A

Corresponds to shape of pressure point

29
Q

What is the base of neuropathic ulcers like?

A

May be deep with bone exposed

30
Q

What is the edge of neuropathic ulcers like?

A

Punched out

31
Q

What are the surroundings of a neuropathic ulcer like?

A 
Skin- looks normal
Charcot's joints
PVD signs if concomitant arterial disease
Absent sensation around ulcer
Absent ankle jerks
32
Q

What are the temperature and peripheral pulses like in neuropathic ulcers?

A

Normal

Present

33
Q

What are the causes of neuropathic ulcers?

A

Any cause of peripheral neuropathy: DM, ETOH, B12

Every vasculitis

34
Q

What is the pathophysiology of neuropathic ulcers?

A

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

Vascular (18 decks)

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