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Vascular Surgery > Ulcers Of Lower Limb > Flashcards

Ulcers Of Lower Limb Flashcards

1
Q

What are ulcers?

A

Abnormal breaks in the skin or mucous membranes

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2
Q

What are the three most common types of ulcers of the lower limb?

A

Venous (80%)
Arterial
Neuropathic (diabetic neuropathy)

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3
Q

What cause venous ulcers?

A

Venous insufficiency

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4
Q

Describe the appearance of venous ulcers?

A

Shallow with irregular borders and granulated base, usually located over the medial malleolus

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5
Q

What are the risk factors for venous ulcers?

A 
Increasing age
Venous incompetence (VTE/Varicose veins) 
Pregnancy 
Obesity or physical inactivity 
Trauma
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6
Q

What are the associated symptoms of chronic venous disease?

A

Aching, itching, or a brusting sensation, will be present often before venous leg ulcers appear

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7
Q

What are the features of venous sufficiency?

A 
Varicose eczema 
Thrombophlebitis 
Haemosiderin skin staining 
Lipodermatosclerosis
Atrophied blanche
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8
Q

How is is underlying venous insufficiency confirmed?

A

Duplex ultrasound

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9
Q

What is used to assess for any arterial component to the ulcers?

A

Ankle Brachial Pressure Index (ABPI)

Asses if whether compression therapy will be suitable

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10
Q

What should you do if suspect infection?

A

Take swab culture and give antibiotics

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11
Q

What is the conservative management for venous leg ulcers?

A

Leg elevation
Increased exercise
Lifestyle change e.g weight loss and improved nutrition

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12
Q

What is the mainstay management for venous ulcers?

A

Multi component compression bandaging

  • change once/twice a week
  • most will heal in 6 months
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13
Q

What other treatment is important in venous ulcers?

A

Appropriate dressings
Emollients
Treating underlying venous insufficiency

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14
Q

What causes arterial ulcers?

A

Reduction in arterial blood flow leading to decreased perfusion of tissues and subsequent poor healing.

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15
Q

How would you describe arterial ulcers?

Where do they occur?

A

Small deep lesions with well -defined borders ad necrotic base

Commonly occurs in sites of trauma and pressure areas

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16
Q

What are the risk factors for arterial ulcers?

A

Peripheral arterial disease, smoking, DM, hypertension, hyperlipidaemia, increasing age, positive family history, obesity and physical inactivity

17
Q

What is the typical history for a pt with suspected arterial ulcer?

A

Intermittent claudication
Critical limb ischaemia (pain at night)

Develops over long period of time with no healing

18
Q

What are the associated signs of arterial ulcers?

A 
Cold limbs
Thickened nails 
Necrotic toes 
Hair loss 
Absent pluses on examination
19
Q

What investigations could be done for suspected arterial ulcers?

A

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)
20
Q

What is the conservative management for arterial ulcer?

A

Lifestyle advise (smoking cessation, weight loss and increased exercise)

21
Q

What is the medical management for arterial ulcers?

A

CVD risk modification:

  • Statin therapy
  • antiplatelet agent (aspirin or clopidogrel)

Optimise BP and Glucose

22
Q

What is the surgical management of arterial ulcers?

A 
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

23
Q

What causes neuropathic ulcers?

A

Peripheral neuropathy leading often to painless ulcers

This is due to loss of protective sensation and repetitive stress and unnoticed injuries.

24
Q

What are the risk factors for neuropathic ulcers?

A

Anything that cause peripheral neuropathy such as:

  • DM
  • B12 deficiency

Foot deformities or concurrent peripheral vascular disease

25
Q

What are their clinical manifestations of neuropathy?

A

Burning/tingling in legs (painful neuropathy)
Single nerve involvement
Amyotrophic neuropathy (painful wasting of proximal quadriceps)

26
Q

What do neuropathic ulcers look like?

Where are they usually found?

A

Variable in size and depth with a “punched out appearance”

Usually found on pressure areas

27
Q

What investigations can be done for neuropathic ulcers?

A

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

28
Q

What is the management for neuropathic ulcers?

A 
Optimised diabetic control
Improve diet and exercise 
Reduced CVD risk factors 
Regular chiropdy 
Appropriate footwear

Ensure signs of infection treated (flucloxacillin)

29
Q

When is surgical intervention required in neuropathic ulcers?

A

Ischaemic or necrotic tissue - surgical debridement

Severe cases may require amputation

30
Q

What is Charcot foot?

A

Neuroarthropathy where by loss of joint sensation result in continual unnoticed trauma and deformity occurring

Loss of transverse arch and “rocker-bottom” sole

31
Q

What is the management for Charcots foot?

A

Specialist review for consideration of off-loading abnormal weight and sometime immobilisation of affected joint in plaster

32
Q

What are some other types of ulcer?

A

Trauma
Connective tissue disease + vasculitis
Malignant

33
Q

What is Marjolins ulceration?

A

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

34
Q

What is important to ask about in a leg ulcer history?

A 
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
35
Q

What investigations may be requested for diabetic/immunocompromised pt with ulcers and why?

A

X-ray/MRI - look for osteomyelitis

Vascular Surgery (3 decks)

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