Venous Ulcers Flashcards
Define chronic venous insufficiency.
Persistent elevation in venous pressures usually due to venous reflux from faulty valves (e.g. due to DVT) which eventually results in oedema, skin changes and frank ulcers.
Are venous ulcers painful?
Only 30% are painful - caused by STASIS in the leg and are thus less painful when elevated and drained of blood.
How common are venous ulcers?
Affects 1-2% of the population - even after treatment 70% recur
What are the risk factors for venous insufficiency/ulcers?
- Age
- FH
- Smoking
- DVT
- Varicose veins
- Orthostatic occupation
- Female
- Obesity
- Immobility (reduced venous drainage of legs)
- Malnourishement (reduced healing)
Other:
- Abdominal tumours (compressing iliac veins)
- Arteriovenous malformations (increasing venous pressure)
- Major joint replacement (e.g. of a hip or knee) - up to 25% of such operations are associated with subclinical DVTs
What is the typical site of a venous ulcer?
What are the characteristics of a venous ulcer?
Gaiter area of legs (area covered by a long sock) - between the medial malleolus and mid calf; venous pressures are highest here and medial malleolus is the site of medial calf perforators.
Characteristics:
- Shallow
- Wet
- Irregular borders
- Look white and fragile
What other signs are associated with chronic venous insufficiency?
- corona phlebectatica - malleolar flare or ankle flare of small intradermal veins is a common early sign
- ankle oedema
- haemosiderin hyperpigmentation - extravasation and death of erythrocytes –> skin pigmentation -
- atrophie blanche - localised round areas of white shiny atrophic skin surrounded by small dilated capillaries
- lipodermatosclerosis - scarring of the underlying tissue, can even cause contracture of the achilles tendon and cause change in shape → “inverted champagne bottle” legs
- varicose veins and reticular veins - dilated, palpable, subcutaneous veins >3 mm in diameter and dilated, non-palpable, subdermal veins <3 mm in diameter respectively
What symptoms of venous insufficiency are related to a venous ulcer?
- Leg fatigue/aching/discomfort
- Heaviness
- Cramps
- Skin burning and itching - due to eczema
What investigations would you do for a venous ulcer?
- Duplex ultrasound + Doppler - assess competence of saphenofemoral and sapheno-popliteal junctions, state of perforators and deep venous system, and whether valve closure time is _>_0.5s.
- ABPI - to exclude arterial causes of ulcer. Below 0.8 ABPI compression stockings must not be used.
- CT/MR venography - detailed venous anatomy
Other:
- Bloods - FBC, ESR, CRP (vasculitis?), albumin (malnutrition?), fasting lipids
- Capillary glucose - DM?
- Urinalysis - glucose, haematuria, proteinuria
- Swabbing - for MC&S
Describe the management of a venous ulcer.
Conservative:
- Compression bandages (MAINSTAY) - for ulcer healing; applied and changed frequently by nurse to reduce pooling of venous blood in lower limbs. Can be done safely if the ABPi is <0.8.
- Graduated class I or II knee-high compression stockings - helpful once ulcer is healed to prevent recurrence
- +/-Adequate nutrition - important to aid healing and replace Vit C and zinc in elderly who may be deficient in key vitamins.
- +/-Lifestyle modification - mobilise to encourage venous flow in legs
- +/-Leg elevation - to reduce blood pressure in limbs
Medical:
- Moisturising cream for eczema - antibiotic creams have no benefit and may damage adjacent skin.
- +/- Pentoxifylline and micronised purified flavonoid fraction (MPFF) - improved healing in studies
Surgical:
- Varicose vein surgery, laser therapy or radiofrequency ablation, foam sclerotherapy - if the ulcer was caused by no obvious superficial variscosites and there is no deep vein incompetence
- Skin grafting
- Venous valvular reconstruction
In this way 80% of venous ulcers will heal within 26 weeks and those that fail may require grafting by plastic or vascular surgeons.
What are the classes of compression stockings?
There are three classes of compression stockings:
- class 1 stockings (low compression) - control oedema
- class 2 (medium compression)
- class 3 (high compression) - are usually required for more advanced CVI.
NB: TED stockings are inadequate for venous insufficiency.
Summarise the differences between site, charceristics and associated signs of venous, arterial and neuropathic ulcers.
Summarise the key points in an arterial, venous and neuropathic ulcer history.
What is pyoderma gangrenosum?
Ulceration which is a complication or systemic inflammatory diseases e.g. inflammatory bowel disease/RA or haematological malignancies. Can occur at stoma sites.
Erythematous nodules or pustules which ulcerate. May present as an ulcer with a purple halo around it.
What do the edges of an ulcer tell you about it?
- Shelved/sloping - healing
- Punched out - ischaemic or syphilis
- Rolled/everted - malignant
- Undermined - TB
Name the three most common locations of pressure sores.
- sacrum
- greater trochanter
- heel
What can a long history of ulcers suggest?
Marjolin ulcer - tumours that most commonly arise from areas of chronic inflammation or injury and develop over many years. Most common in old burn scars, but also seen in traumatic wounds, venous stasis ulcers, pressure sores, osteomyelitic fistulas, and other chronic wounds.
What is this sign?
Atrophie blanche
Describe the superficial venous system.
Describe the deep venous system.
