Ulcers Flashcards
What causes venous ulcers
Venous hypertension due to insufficiency
Incompetence valves caused by varicose veins / DVT
Leads to oedema
What are other RF
Immobility
Malnourishment
Recent major joint replacement
What are symptoms
Asymptomatic General discomfort / ach Often painful Worse during the day / prolonged standing Relieved raising the leg Itchy skin
What area
Common in gaiter region
Common in malleolar (medial > lateral)
What is seen O/E
Large shallow irregular ulcer Exudative Red / pink granulation tissue Yellow slough Pitting oedema = 1st sign Venous eczema Haemosiderin staining Varicose veins Present pulses + warm skin
What is risk of venous ulcer
Develop into Marjolin’s ulcer
Irregular, raised, foul smelling
What is needed
Inspection
Lavage
Wide excision of necrotic and malignant tissue
How do you investigate venous ulcers
ABPI to ensure not arterial - will be normal
Venous duplex to look for reflux / thrombosis and asses function
How do you manage
Principles of wound management - Inspection - Remove devitalised - Dressing Must treat underlying cause May need Ax if infection Possible surgery for various veins
What do you do for oedema
Compression bandaging
Elevation
Rarely diuretics
What causes arterial ulcers
Insufficient arterial supply PVD Smoking Age DM Hypertension Hyperlipid
What are symptoms
Critical ischaemia pain
Get pain at rest
Worse lying flat
Releived by standing or hanging feet over bed
What are signs on examination
Small sharply defined deep ulcer PAINFUL Necortic base Well demarcated Pale and dry Little granulation May see necrosis Hair loss Cold skin Prolonged CRT Absent pulses Shiny pale skin Loss of hair
What is Buerger
Elevate foot up to 30 degrees
Leads to colour fading and pain
When hang foot over bed then becomes deep red as fills with blood
How do you investigate
ABPI
Dupplex USS + angio
Percutaenous USS
How do you Rx
Basic wound
RF modification
Angioplasty or stent
Surgery - bypass or amputation
What causes diabetic foot ulcers
Hyperglycaemia = neuropathy and PVD Autonomic = dry cracked skin Motor = foot drop / deformity
What are symptoms
Sensory loss so ulcer are not painful
Foul smell if infected
Sx of poor glycemic control
What is seen O/E
Typically plantar
Thickened surrounding skin
Infection
What is common cause of amputation
Infection
How do you prevent
Education BG control Self foot care - examine regular, footwear, toenail care Identify RF Regular foot review
How do you Rx
Basic wound
Minimise neuropathy
Treat ischaemia - same as arterial
How do you minimise neuropathy
Offloading
Custom footwear
Resection of wound / bony deformity
What are pressure sores
Breakdown of skin and underlying tissue 2 to unrelieved pressure or friction
Where are common sites
Sacrum
Ischial tubersoity
Greater trochanter of femur
Heels
What are RF
Immobile Incontinence Poor nutrition Poor sensation Age
Stage 1
Non-blanching erythema
Red, warm, painful oedema
Skin intact
Stage 2
Partial loss of epidermis or dermis
Often shallow ulcer with red / pink wound bed
No slough
Stage 3
Full thickness loss
Subcutaneous involvement
Stage 4
Full thickness loss
Involvement of muscle / bone / tendon
What does stage 4 have high risk of
OM
How do you prevent
Risk assess WATERLOW
Air mattress
Pressure relief
How do you Rx
Basic wound management Plastic surgeon for skin graft Nutrition Mobilisation Support surfaces / mattress
What is typical history of neuropathic ulcer
Often painless
Abnormal sensation
Hx DM / neuro disease
What is ulcer like
Common on pressure sites - Heel / toes / metatarsals Variable size and depth Maybe surrounded by hyperkeratotic lesion e.g. callus Warm skin Normal pulses Peripheral neuropahty
What are possible investigations
ABPI
If <0.8 implies neuroischaemic ulcer common in DM
X-ray to exclude OM
How do you manage
Wound debridement
Regular repositioning
Appropriate footwear
Good nutrition
What are other types of ulcer
Vasculitic- purpuric and punched out
Infected - dischagrge + systemic unwell
Malignancy - SCC on background of chronic inflammation / non-healing ulcer
