Vascular: Lower Limb Ulcers

Question 1

Describe the pathophysiology of venous ulcers

Answer 1

Valvular incompetence/obstruction = impaired venous return = venous hypertension = “trapping” of WBC in capillaries = activated, release of inflammatory mediators = tissue injury, poor healing, necrosis

Question 2

What are the symptoms of venous ulcers?

Answer 2

Shallow, irregular borders, granulating base

Characteristically located over the medial malleolus (gaiter region)

Prone to infection and can present with associated cellulitis

Painful

Venous insufficiency = oedema, varicose eczema or thrombophlebitis, haemosiderin skin staining, lipodermatosclerosis, or atrophie blanche

Question 3

How should venous ulcers be investigated?

Answer 3

Duplex US

ABPI

Swab cultures

Question 4

How should venous ulcers be managed?

Answer 4

Leg elevation

Lifestyle = increase exercise (promoting calf action), weight reduction, improved nutrition

Abx

Multicomponent compression bandaging with emollients
- Make sure ABPI is >0.6

Concurrent varicose veins = endovenous techniques or open surgery (improved venous return = healing)

Question 5

Describe the pathophysiology of arterial ulcers

Answer 5

Reduction in arterial blood flow = decreased perfusion of the tissues = poor healing

Question 6

Discuss the symptoms of arterial ulcers

Answer 6

Small deep lesions

Well-defined borders

Necrotic base with little granulation tissue

Occur at sites of trauma and pressure

Intermittent claudication

Critical limb ischemia (pain at night)

Pain

Limbs will be cold

Reduced/absent pulses

Sensation is maintained

Question 7

What are the investigations for arterial ulcers?

Answer 7

ABPI 
>0.9 = normal
0.9-0.8 = mild
0.8-0.5 = moderate
<0.5 = severe

Duplex US

CT angiography

MR angiography

Question 8

How should arterial ulcers be managed?

Answer 8

Urgent referral for vascular review

Lifestyle = smoking cessation, weight loss, increased exercise

Medical = statin, aspirin/clopidogrel, optimising BP and glucose

Surgical = angioplasty, bypass grafting, skin graft

Question 9

Outline the pathophysiology of neuropathic ulcers

Answer 9

Loss of protective sensation = repetitive stress = unnoticed injuries = painless ulcers on pressure points

Concurrent vascular disease will often contribute to their formation and reducing healing potential

Question 10

What are the symptoms of neuropathic ulcers?

Answer 10

Burning/tingling in legs

Single nerve involvement (mononeuritis multiplex, such as CN III or median nerve)

Amotrophic neuropathy (painful wasting of proximal quadriceps)

Variable in size/depth

Punched out appearance

Most commonly on the foot pressure sites

Peripheral neuropathy (classically in a ‘glove and stocking’ distribution) with warm feet and good pulses

Question 11

How should neuropathic ulcers be investigated?

Answer 11

Assess peripheral neuropathy = monofilament, 128Hz tuning fork

Blood glucose

B12

ABPI

Duplex US

Microbiology swab

X-ray = assess osteomyelitis

Question 12

Outline the management of neuropathic ulcers

Answer 12

Diabetic foot clinic

Targeting HbA1c <7%

Lifestyle = improved diet, increased exercise

Regular chiropody

Abx

Debridement

Amputation = in severe cases

Question 13

What is Charcot’s foot?

Answer 13

Loss of joint sensation = unnoticed trauma/deformity = neuropathic ulcer formation

Swelling, distortion, pain, loss of function

Loss of transverse foot = rocker bottom sole

Requires specialist review for off-loading abnormal weight, immobilisation of affected joint in plaster