Vascular: Leg Ulcers Flashcards
Define the term ‘ulcer’.
Breach in continuity of skin, epithelium or mucous membrane, caused by sloughing out of inflamed necrotic tissue.
What are the 4 most common diagnoses for leg ulcers?
- Venous ulcer
- Arterial (atherosclerotic) ulcer
- Mixed arterial/venous ulcer
- Neuropathic ulcer
where are each of the 3 main types of ulcer more commonly found?
Venous: where venous pressures are highest - gaiter area, esp. medial. Most common area is just above medial malleolus as is site of medial calf perforators.
Arterial: where arterial supply is worst (distal areas) and those frequently compressed - ball of foot, between toes, tips of toes, lateral malleolus.
Neuropathic: pressure areas of foot where foot rubs on poorly-fitting footwear (e.g. beneath metatarsal heads)
describe the appearance of the 3 main types of ulcer
Venous:
- irregular, sloping white edges
- shallow and wet
Arterial:
- well-defined, punched-out edges (often elliptical)
- deep and dry
Neuropathic:
- very thick, keratinised raised callous edges
which Ix would you perform on someone with an ulcer?
Bloods:
- FBC: ?infection, ?anaemia
- ESR or CRP: ?vasculitis
- albumin: ?malnutrition
- fasting lipids: ?hyperlipidaemia (contributing to any atherosclerosis)
- glucose: ?diabetes
Bedside tests:
- urinalysis: look for glucose (?DM) and haematuria/proteinuria (?vasculitis)
- duplex USS: to assess competence of sapheno-femoral and sapheno-popliteal junctions, and state of perforators and deep venous system
- ankle-brachial pressure index (ABPI): to assess for arterial disease (perform even if convinced ulcer is venous as if ABPI <0.8, pt must not have pressure bandage applied, may be mixed ulcer)
how would you interpret various ABPI results?
ABPI 1 = normal
ABPI 0.5-0.8 = arterial disease, requires referral to vascular clinic for further assessment
ABPI <0.5 = arterial ulcers, compression treatment contraindicated. Requires referral to vascular clinic for further assessment and possible revascularisation.
how would you manage a pt with venous ulcers?
- Lifestyle modification: adequate nutrition (improve healing) and mobilisation (encourage blood flow)
- Leg elevation whenever possible (reduce BP in legs)
- Compression bandages applied and frequently changed (reduce pooling of blood in lower limbs)
how can venous ulcer recurrence be prevented once they are healed?
- graduated class I or II elastic stockings
- varicose vein surgery if ulcer caused by obvious superficial varicosities and there is no deep vein incompetence
how would you manage a pt with arterial ulcers?
Involves Mx of pts with critical limb ischaemia:
- lifestyle modification: smoking cessation, weight loss, increased exercise
- statin therapy (reduce hyperlipidaemia)
- antiplatelet agent (e.g. aspirin or clopidogrel) (reduce risk of blood clots)
- BP optimisation via antihypertensive therapy
- surgery in severe cases: angioplasty (with or without stenting) or bypass grafting
how would you manage a pt with neuropathic ulcers?
- regular dressings
- optimisation of diabetic control - aim for HbA1c <7%
- regular chiropody to maintain good foot hygiene and appropriate footwear
- if signs of infection: swabs and antibiotics (e.g. flucloxacillin)
- ischaemic or necrotic tissue may require surgical debridement or amputation