Venous and arterial Ulcers Flashcards
What are the key steps to taking an ulcers history?
Asking about the symptoms experienced (onset, progression, and severity)
Identifying risk factors, such as immobility and a history of deep vein thrombosis
Examining the wound (site, edge, size, depth, wound bed, and look for signs of infection)
Examining both legs (for oedema, varicose veins, venous skin changes, peripheral neuropathy and reduced ankle mobility)
Assessing for other causes of ulceration and/or delayed wound healing
Measuring the ankle-brachial pressure index in both legs to exclude arterial insufficiency
What is an arterial ulcer?
Arterial ulcers, also known as ischemic or arterial insufficiency ulcers, stem from inadequate blood supply to the extremities.
What is the main cause of an arterial ulcer?
Atherosclerosis
Where do arterial tend tooccur?
Lower extremities near the end-arteries
1. Toes
2. Heels
3. lateral malleolus
What pain is experienced typically in an arterial ulcer.
- severe resting pain due to ischaemia
- Painful, especially at night
- Pain worse when elevated
How do arterial ulcers typically appear?
- Pale
- Dry
- Gangrenous
- Cool surrounding skin
- Sharply defined
- Have a deep punched out appearance
- Loss of hair on surrounding skin
What are the pulses like in the effected area of an arterial ulcer?
Diminished or absent pulses, especially in the affected limb, are a hallmark sign.
What 3 investigations are used to investigate arterial ulcers?
- Doppler Ultrasound
- ABPI (<0.8 = arterial insufficiency)
- Angiography
what is the epidemiology of arterial ulcers?
- ELDERLY
- men
what is the aetiology of arterial ulcers?
- atherosclerosis > peripheral arterial disease > inadequate blood supply to the distal extremities
what are the differentia diagnosis of arterial ulcers?
-diabetic ulcers
- vasculitis ulcers
- malignant ulcers
what is the management of arterial ulcers?
- treat the underlying cause
- improving arterial circulation via lifestyle changes eg smoking cessation, weight loss, supervised group exercise for collateral blood supply
- medications = clopidogerol, atorvastatin , BP and DM control
- angioplasty or bypass surgery when severe
What is contradicted is arterial ulcers are present?
Compression bandaging and anti-embolism stockings as this could further reduce distal blood flow
What type of ulcer is likely to be found on the ankle and calf?
Venous
What type of ulcer is likely to be found in areas of pressure?
diabetic ulcer
What type of ulcer is likely to be found on the lateral foot and lower leg?
Arterial
Define ‘ulcer’:
excavation of the surface of an organ or tissue that is produced by sloughing of inflammatory necrotic tissue
What is the most common type of lower limb ulcer?
Venous
Name 5 types of lower limb ulcer:
1) arterial
2) venous
3) pyoderma gangrenosum
4) neuropathic
5) pressure
What is the most common cause of arterial ulcers?
peripheral vascular disease
What is the main cause of venous ulcers?
venous hypertension - high pressures in the veins of the legs makes healing difficult after a minor injury
Where are venous ulcers most commonly found?
medial malleolus (and lateral)
Describe the appearance of venous ulcers:
superficial with ill-defined boarders and may produce exudate
What is chronic venous insufficiency?
refers to functional changes that may occur in the lower extremities due to persistent elevation of venous pressures. This most commonly results from venous reflux due to faulty valve function developing as a long-term sequelae of deep vein thrombosis or varicose veins
How does chronic venous insufficiency lead to venous ulcers?
esulting in increased venous pressure and impaired tissue oxygenation, triggering inflammation and tissue damage
What is the pain like in a venous ulcer?
- Aching or heaviness in affected limb.
- Pain worsens with prolong standing
- Pain improves with leg elevation
Name 5 findings that may be associated with venous ulcers:
- Varicose veins
- Lipodermatoaschlerosis
- venous flare
- Atrophie blanche
- varicose eczema
What is lipodermatosclerosis?
hardening/ scarring of skin and fat
What is venous flare?
spindly veins on the ankles and calf
What 3 investigations are used in venous ulcers?
- Doppler ultrasound
- Venous duplex ultrasound
- Venous pressure measurement
epidemiology of venous ulcers?
- ELDERLY
- middle-aged females
what are the clinical features of venous ulcers?
- gaiter area (medial)
- large and shallow
- sloping edges
- bleed or ooze
- associated with features of chronic venous insufficiency eg haemosiderin deposits, lipoderatosclerosis and firm oedema
what are the differential diagnosis for venous ulcers?
- diabetic ulcers
- vasculitic ulcers
- malignant ulcers
what is the management of venous ulcers?
- treating the underlying cause
- compression stockings to reduce venous hypertension
- promote wound healing
- surgical intervention for severe cases
What is pyoderma gangrenosum?
neutrophilic dermatitis associated with IBD that leads to small red bumps that turns into painful ulcers
What are neuropathic ulcers?
an ulcer caused by peripheral neuropathy e.g. diabetic neuropathy or trauma
Where are neuropathic ulcers typically found?
feet
Give two potential treatments for venous ulcers:
1) compression therapy
2) pentoxifylline
How do neuropathic ulcers usually present?
Variable size and depth. Surrounding skin may be warm, dry, and calloused.
Typically occur in numb skin
What is the pain like in neuropathic ulcers?
These ulcers are often painless due to sensory neuropathy. Patients may not notice the ulcer until it becomes severe.
What pulses can be felt in neuropathic ulcers?
Pulses are usually present and normal in neuropathic ulcers, although they can be absent if there is concomitant arterial insufficiency.
What investigations are used for neuropathic ulcers?
Primarily clinical
X-ray may be used to rule out osteomyelitis
What is the management of neuropathic ulcers?
Wound care is crucial to maintain a moist wound environment with appropriate dressings. Tissue viability nurses can support with dressing choice, and these patients may also be seen in a dedicated foot clinic.
Glycaemic control and optimisation of diabetes management should be reviewed in these patients to slow the progression of neuropathy
Describe compression therapy as a treatment for venous ulcers:
2/3 bandages are layered with orthopaedic wadding plus wound contact dressing
What type of drug is pentoxifylline?
Methylxanthine
Describe how pentoxifylline can help treat venous ulcers:
it increases microvascular blood flow to enhance oxygenation of ischaemic tissue and aid healing
