Venous & Arterial Ulcers Flashcards
1
Q
What is the definition of an ulcer?
A
ulcers are abnormal breaks in the skin or mucous membranes
2
Q
What are the majority of lower limb ulcers caused by?
What are more rare causes of lower limb ulcers?
A
- 80% of lower limb ulcers have a venous origin
- other common causes are arterial insufficiency and diabetic-related neuropathy
- rarer causes are:
- trauma
- infection
- vasculitis
- malignancy (usually squamous cell carcinoma)
3
Q
What type of ulcer may also occur in someone who is less mobile?
A
pressure ulcers
- these are caused by prolonged or excessive pressure over a bony prominence
- this leads to skin breakdown and eventual necrosis
4
Q
How is the appearance of venous and arterial ulcers different?
A
Venous ulcers:
- shallow ulcers with a granulated base
- there are often other clinical features of venous insufficiency present
Arterial ulcers:
- tend to be found at distal sites with other evidence of arterial insufficiency
- they are often “punched-out” lesions with well-defined borders
5
Q
What are neuropathic ulcers and where do they typically occur?
A
- painless ulcers over areas of abnormal pressure, often secondary to joint deformity in diabetics
6
Q
What directly causes a venous ulcer?
How can they be identified and where are they most commonly found?
A
- caused by venous insufficiency
- they are shallow with irregular borders and a granulating base
- they are typically located over the medial malleolus
7
Q
How do venous ulcers typically present to the GP?
A
- they are prone to infection so often present with associated cellulitis
8
Q
What is thought to be the pathophysiology behind why venous ulcers occur?
A
- valvular incompetence or venous outflow obstruction leads to impaired venous return
- this leads to venous hypertension
- this causes trapping of WBCs in capillaries and the formation of a fibrin cuff around the vessel
- this hinders oxygen transportation into the tissue
- WBCs become activated and release inflammatory mediators, leading to resultant tissue injury, poor healing and necrosis
9
Q
What are the risk factors for developing venous ulcers?
A
- increasing age
- pre-existing venous incompetence or history of VTE
- this includes varicose veins
- pregnancy
- obesity or physical inactivity
- severe leg injury or trauma
10
Q
Are venous ulcers painful?
What associated symptoms of chronic venous disease may be present alongside the ulcer?
A
- they can be painful and are worse at the end of the day
- they are often found in the gaiter region of the legs
- associated symptoms of chronic venous disease are aching, itching or a burning sensation
- these are often present before venous leg ulcers appear
11
Q
When examining a venous ulcer, what features associated with venous insufficiency might be present?
A
- varicose eczema
- thrombophlebitis (blood clot in one or more veins)
- haemosiderin skin staining
- lipodermatosclerosis
- atrophie blanche
12
Q
What is haemosiderin deposition and why does it occur?
A
- haemosiderin deposition occurs due to venous insufficiency and blood pooling in the veins
- haemosiderin staining occurs when red blood cells leak through the veins
- iron pigments leak into the skin, which shows up as brown patches or stains
13
Q
What is lipodermatosclerosis?
What does it look like?
A
- a chronic inflammatory condition characterised by subcutaneous fibrosis and hardening of the skin on the lower legs
- it is a panniculitis (inflammation of the layer of fat under the epidermis)
14
Q
What is atrophie blanche?
A
- it describes the result of healed ulcers
- it presents as a white, atrophic stellate scars with peripheral telangiectasia
- it occurs after skin injury when the blood supply is poor and healing is delayed
15
Q
How are venous ulcers diagnosed?
Where does venous incompetence most commonly occur?
A
- they are diagnosed clinically
- underlying venous insufficiency is confirmed with Duplex Ultrasound
- venous incompetence occurs at the sapheno-femoral or sapheno-popliteal junctions
16
Q
Why is ankle-brachial pressure index (ABPI) assessed when there is a venous ulcer?
A
- ABPI is required to assess whether there is an arterial component to the ulcers and to determine whether compression therapy will be suitable
17
Q
What other test might be considered if a venous ulcer is erythematous or with purulent exudate?
A
- this means that infection should be suspected
- swab cultures should be taken
- antibiotics should be given
18
Q
What should be considered in younger patients presenting with venous ulcers?
A
- consider a thrombophilia and vasculitic screening in young patients
- especially if there is a suspicion or family history of prothrombotic and autoimmune diseases
19
Q
What is involved in the conservative management for venous ulcers?
A
- leg elevation and increased exercise
- this promotes the calf muscle pump action, which aids venous return
- lifestyle changes such as improved diet and weight reduction should also be encouraged
20
Q
When are antibiotics prescribed for venous ulcers?
A
- ONLY when there is clinical evidence of a wound infection
- most wounds are colonised, so swab results should only be acted upon if there is evidence of infection
21
Q
What is the main method of management for venous ulcers?
A
multicomponent compression bandaging
- these should be changed once or twice a week for 6 months
- this improves healing time
22
Q
What measurement must be taken before applying compression bandaging?
What can be used alongside this to promote skin health?
A
- ABPI must be at least 0.6 or more before any bandaging is applied
- appropriate dressings and emollients are crucial to maintain the health of the surrounding skin
23
Q
What causes an arterial ulcer?
A
- it is caused by reduction in arterial blood flow
- this leads to decreased perfusion of the tissues and subsequent poor healing
24
Q
What do arterial ulcers typically look like?
Where do they most commonly occur?
A
- they form small deep lesions with well-defined borders and a necrotic base
- they most commonly occur distally at sites of trauma and in pressure areas (e.g. heel)
25
What are the risk factors for developing arterial ulcers?
the main risk factors are those of **peripheral arterial disease**
* smoking
* diabetes
* hypertension
* hyperlipidaemia
* increasing age
* positive family history
* obesity and physical inactivity
26
What other symptoms are usually present in the history of someone presenting with an arterial ulcer?
* history of **_intermittent claudication_**
* this is pain on walking
* history of **_critical limb ischaemia_**
* this is pain at night
27
How long does it take for an arterial ulcer to develop?
What are other associated signs that might be present?
* they are **painful** ulcers that develop over a **_long period of time_**
* there is **_little to no healing_**, meaning there is **no or little granulation tissue**
* associated signs include:
* cold limbs
* thickened nails
* necrotic toes
* hair loss
28
In someone with an arterial ulcer, what will the limb be like on examination?
What signs need to be assessed for?
* the limbs will be **_cold_** and have reduced or **_absent pulses_**
* in pure arterial ulcers, **sensation is maintained** (unlike neuropathic ulcers)
* assess for signs of **_venous insufficiency_** as some patients have **mixed pathology**
29
Why is an ABPI performed on a suspected arterial ulcer and what readings would be pathological?
* ABPI can quantify the **extent of any peripheral arterial disease**
* \> 0.9 is normal
* 0.8 - 0.9 is mild
* 0.5 - 0.8 is moderate
* \< 0.5 is severe
30
What is involved in the conservative management of arterial ulcers?
* patients should be advised about **lifestyle changes**, such as:
* smoking cessation
* weight loss
* increased exercise
31
What is involved in the medical management of arterial ulcers?
* suitable pharmacological **cardiovascular risk factor modification** should be prescribed
* this includes **_statin therapy_**
* with an **_antiplatelet agent_**, such as **aspirin** or **clopidogrel**
* and optimisation of **blood pressure** and **glucose**
32
When might surgical management of arterial ulcers be considered?
What does this involve?
* this involves ***angioplasty*** (with or without stenting) or ***bypass grafting*** for more extensive disease
* any ***non-healing ulcers***, despite a good blood supply, may also be offered skin reconstruction with grafts
33
What is a neuropathic ulcer?
Why do they tend to occur and what concurrent disease can contribute to their formation?
* it is an ulcer that occurs as a result of **_peripheral neuropathy_**
* there is a **loss of protective sensation**, leading to **_repetitive stress_** and unnoticed injuries forming
* this results in **_painless ulcers_** forming on the **pressure points** of the limb
* **_concurrent vascular disease_** contributes to their formation and **reduces healing potential**
34
What are the risk factors for neuropathic ulcers?
* they can develop with any condition with **peripheral neuropathy**
* the most common is **_diabetes mellitus_** and **_vitamin B12 deficiency_**
* ulcer risk is increased further by any **_foot deformity_** or concurrent **_peripheral vascular disease_**
35
What are the key factors to pick up in the history of someone presenting with neuropathic ulcers?
* history of **peripheral neuropathy** (although patient might be unaware)
* or symptoms of **peripheral vascular disease**
36
What are other clinical manifestations of neuropathic ulcers?
* **_burning / tingling_** in the legs (***painful neuropathy***)
* **_single nerve involvement_** (***mononeuritis multiplex***)
* usually involves CN III or the median nerve
* **_painful wasting_** of the **_proximal quadriceps_** (***amotrophic neuropathy***)
37
What do neuropathic ulcers look like on examination?
Where do they commonly occur?
* they are **variable** in size and depth
* they have a **_"punched out"_** appearance
* they occur most commonly on **_sites of pressure on the feet_**, such as the **metatarsal heads** or **heels**
38
What does the limb typically look like on examination in a neuropathic ulcer?
What other symptom may be present?
* there may be **_peripheral neuropathy_**, which is typically in a ***"glove and stocking"*** distribution
* the feet should be **_warm with good pulses_** unless there is an element of **concurrent arterial disease**
39
What initial investigations are carried out if a neuropathic ulcer is suspected?
* **_blood glucose levels_** should be checked - either ***random glucose*** or ***HbA1c***
* **_serum B12 levels_** should be checked
* **concurrent arterial disease** should be assessed with an **_ABPI +/- duplex_**
40
What additional investigations are conducted in neuropathic ulcers if infection is suspected?
* signs of infection require a **_microbiology swab_**
* signs of **deep infection** (e.g. visible bone or ulcers extending into joints) may warrant an **_X-ray_** to assess for **_osteomyelitis_**
41
How is the extent of peripheral neuropathy assessed?
* using the **10g monofilament** or **Ipswich touch test**
* along with testing vibration sensation with a **128Hz tuning fork**
42
What steps are involved in the management of neuropathic ulcers?
* diabetic control should be optimised, targeting HbA1c \< 7%
* improved diet and increased exercise (within limits) is encouraged
* cardiovascular risk factors need to be managed
* regular chiropody to maintain good foot hygiene and appropriate non-weight bearing footwear
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