Venous ulcers

Question 1

Define

Answer 1

• Large, shallow, sometimes painful ulcers usually found superior to the medial malleoli. They are caused by incompetent valves in the lower limbs leading to venous stasis and ulceration.

Question 2

What’s the aetiology?

Answer 2

• They are caused by incompetent valves in the lower limbs
• Valve incompetence leads to venous stasis and increased venous pressure
• This results in ulceration

Question 3

What are the risk factors?

Answer 3

o	Obesity 
o	Immobility
o	Recurrent DVT 
o	Varicose veins 
o	Previous injury/surgery to the leg 
o	Age

Question 4

What’s the epidemiology?

Answer 4

• VERY COMMON

* Increases with age

Question 5

What are the presenting symptoms?

Answer 5

•	Large, shallow, relatively painless ulcer with an irregular margin situated above the medial malleoli (most of the time) 
•	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 are the signs?

Answer 6

•	Described above 
•	Other signs of venous ulcers:
o	Stasis eczema 
o	Lipodermatosclerosis (hardening of the skin) (inverted champagne bottle sign if SEVERE)
o	Haemosiderin deposition (dark colour)

Question 7

What are the appropriate investigations?

Answer 7

• Doppler assessment and ABPI (ankle brachial pressure index)
o Exclude arterial ulcer
o If ABPI < 0.8 - do NOT apply a pressure bandage as this could worsen the ulcer
• Measure surface area of ulcer - allows monitoring of progression
• Swabs for microbiology - if signs of infection
• Biopsy - if possibility of Marjolin’s ulcer

Question 8

What’s the management plan?

Answer 8

• Graduated compression (reduced venous stasis)
o NOTE: must exclude diabetes, neuropathy and PVD before this is attempted
• Debridement and cleaning
• Antibiotics - if infected
• Topical steroids - may help with surrounding dermatitis

Question 9

What are the possible complications?

Answer 9

• Recurrence

* Infection

Question 10

What’s the prognosis?

Answer 10

• GOOD

* Results are better if patients are mobile with few comorbidities

Question 11

What are the risk factors?

Answer 11

o	Obesity 
o	Immobility
o	Recurrent DVT 
o	Varicose veins 
o	Previous injury/surgery to the leg 
o	Age