Ulcers Of Lower Limb Flashcards
What are ulcers?
Abnormal breaks in the skin or mucous membranes
What are the three most common types of ulcers of the lower limb?
Venous (80%)
Arterial
Neuropathic (diabetic neuropathy)
What cause venous ulcers?
Venous insufficiency
Describe the appearance of venous ulcers?
Shallow with irregular borders and granulated base, usually located over the medial malleolus
What are the risk factors for venous ulcers?
Increasing age Venous incompetence (VTE/Varicose veins) Pregnancy Obesity or physical inactivity Trauma
What are the associated symptoms of chronic venous disease?
Aching, itching, or a brusting sensation, will be present often before venous leg ulcers appear
What are the features of venous sufficiency?
Varicose eczema Thrombophlebitis Haemosiderin skin staining Lipodermatosclerosis Atrophied blanche
How is is underlying venous insufficiency confirmed?
Duplex ultrasound
What is used to assess for any arterial component to the ulcers?
Ankle Brachial Pressure Index (ABPI)
Asses if whether compression therapy will be suitable
What should you do if suspect infection?
Take swab culture and give antibiotics
What is the conservative management for venous leg ulcers?
Leg elevation
Increased exercise
Lifestyle change e.g weight loss and improved nutrition
What is the mainstay management for venous ulcers?
Multi component compression bandaging
- change once/twice a week
- most will heal in 6 months
What other treatment is important in venous ulcers?
Appropriate dressings
Emollients
Treating underlying venous insufficiency
What causes arterial ulcers?
Reduction in arterial blood flow leading to decreased perfusion of tissues and subsequent poor healing.
How would you describe arterial ulcers?
Where do they occur?
Small deep lesions with well -defined borders ad necrotic base
Commonly occurs in sites of trauma and pressure areas
What are the risk factors for arterial ulcers?
Peripheral arterial disease, smoking, DM, hypertension, hyperlipidaemia, increasing age, positive family history, obesity and physical inactivity
What is the typical history for a pt with suspected arterial ulcer?
Intermittent claudication
Critical limb ischaemia (pain at night)
Develops over long period of time with no healing
What are the associated signs of arterial ulcers?
Cold limbs Thickened nails Necrotic toes Hair loss Absent pluses on examination
What investigations could be done for suspected arterial ulcers?
Ankle Brachial pressure index (ABPI)
(>0.9 = normal, 0.9-0.8 = mild, 0.8-0.5 = moderate, <0.5 = severe)
Clinical examination followed by:
- Duplex ultrasound
- CT angiography
- Magnetic Resonance Angiogram (MRA)
What is the conservative management for arterial ulcer?
Lifestyle advise (smoking cessation, weight loss and increased exercise)
What is the medical management for arterial ulcers?
CVD risk modification:
- Statin therapy
- antiplatelet agent (aspirin or clopidogrel)
Optimise BP and Glucose
What is the surgical management of arterial ulcers?
Angioplasty (with or without stenting) Bypass grafting (more extensive disease)
For non-healing ulcers despite a good blood supply may also be offered skin reconstruction with grafts
What causes neuropathic ulcers?
Peripheral neuropathy leading often to painless ulcers
This is due to loss of protective sensation and repetitive stress and unnoticed injuries.
What are the risk factors for neuropathic ulcers?
Anything that cause peripheral neuropathy such as:
- DM
- B12 deficiency
Foot deformities or concurrent peripheral vascular disease
What are their clinical manifestations of neuropathy?
Burning/tingling in legs (painful neuropathy)
Single nerve involvement
Amyotrophic neuropathy (painful wasting of proximal quadriceps)
What do neuropathic ulcers look like?
Where are they usually found?
Variable in size and depth with a “punched out appearance”
Usually found on pressure areas
What investigations can be done for neuropathic ulcers?
Blood glucose ( HBA1c), serum B12 levels
ABPI +/- duplex ultrasound
If evidence of deep infection - microbiology swab and X-ray (for osteomyelitis)
Monofilament test + asses vibration with 128Hz tuning fork
What is the management for neuropathic ulcers?
Optimised diabetic control Improve diet and exercise Reduced CVD risk factors Regular chiropdy Appropriate footwear
Ensure signs of infection treated (flucloxacillin)
When is surgical intervention required in neuropathic ulcers?
Ischaemic or necrotic tissue - surgical debridement
Severe cases may require amputation
What is Charcot foot?
Neuroarthropathy where by loss of joint sensation result in continual unnoticed trauma and deformity occurring
Loss of transverse arch and “rocker-bottom” sole
What is the management for Charcots foot?
Specialist review for consideration of off-loading abnormal weight and sometime immobilisation of affected joint in plaster
What are some other types of ulcer?
Trauma
Connective tissue disease + vasculitis
Malignant
What is Marjolins ulceration?
Longs standing ulcer for many years that has waxed and settled but recently has got worse with raised edge - seen to be a squamous cell carcinoma
What is important to ask about in a leg ulcer history?
Onset, duration, pain, progression Treatment and response Dressing -type/freq Use of compression - helps get rid of fluid to stop infections occurring Use of elevation Mobility Comorbidites Medications - steroids, DMARDS, diuretics
What investigations may be requested for diabetic/immunocompromised pt with ulcers and why?
X-ray/MRI - look for osteomyelitis
