Venous ulcers

Question 1

What are venous ulcers?

Answer 1

Large, shallow, sometimes painful ulcers usually found above the medial malleoli (of the ankle).
- ~80% of lower limb ulcers (usually found in the gaiter region) 

Question 2

What causes a venous ulcer?

Answer 2

They are caused by incompetent valves in the lower limbs = venous stasis and ulceration.

Question 3

What are the risk factors for a venous ulcer?

Answer 3

• Obesity 
• Immobility 
• Recurrent DVT 
• Varicose veins (valvular insufficiency –> tortuous, dilated veins of superficial venous system) 
• Previous injury/surgery to the leg 
• Age 

Question 4

What signs of a venous ulcer can be found on physical examination?

Answer 4

• Usually painless 
• Irregular sloping edges 
• Heavy exudate - ‘wet’  Surrounding skin 
• Stasis/venous eczema - B 
• Lipodermatosclerosis (inverted champagne bottle sign if SEVERE) - A 
• Haemosiderin deposition (dark colour) - A 

Question 5

What are the presenting symptoms of a venous ulcer?

Answer 5

1. Large, shallow, relatively painless ulcer with an irregular margin situated above the medial malleoli (most of the time)
2. Features of the history:
   o Varicose veins
   o DVT
   o Phlebitis
   o Fracture, trauma or surgery
   o Family history
   o Other symptoms of venous insufficiency:
   *Swelling
   *Itching
   *Aching

Question 6

What investigations are used to diagnose/ monitor venous ulcers?

Answer 6

Clinical diagnosis 
1. Duplex ultrasound -to assess underlying venous insufficiency 
2. ABPI (ankle brachial pressure index) 
3. Exclude arterial ulcer
4. If ABPI < 0.8 - doNOTapply a pressure bandage as this could worsen the ulcer 
5. Measure surface area of ulcer - allows monitoring of progression 
6. Swabs for microbiology - if signs of infection 
7. Biopsy - if possibility of Marjolin’s ulcer 

Question 7

How are venous ulcers managed?

Answer 7

1. Conservative management: leg elevation, increased exercise, weight reduction, improved nutrition 
2. Graduated compression 4-layer bandaging (reduced venous stasis) 
3. NOTE: must exclude diabetes, neuropathy and PVD before this is attempted 
4. Debridement and cleaning 
5. Antibiotics - if infected 
6. Topical steroids - may help with surrounding dermatitis 

Question 8

Identify possible complications of venous ulcers

Answer 8

● Recurrence
● Infection

Question 9

Summarise the prognosis for patients with venous ulcers

Answer 9

● GOOD
● Results are better if patients are mobile with few comorbidities