Week 3 - C - Leg ulcers - Types, A.B.P.I, Venous ulcer causes, swabbing, Mx (dressing, bandages, slough), prophylaxis

Question 1

What is a chronic leg ulcer defined as?

Answer 1

Chronic leg ulcer is defined as an open lesion between the knee and ankle joint that remains unhealed for at least 4 weeks

Question 2

What is the most common type of leg ulcers? What are other types?

Answer 2

The majority of leg ulcers are venous leg ulcers

Other types include:

• Arterial ulcers
• Rheumatoid arthritis ulcers
• Diabetic ulcers
• Mixed arterial venous

Question 3

What is the initial procedure that is carried out when finding a leg ulcer? and why?

Answer 3

Initial procedure is to carry out an ankle pressure brachial index measurment using a Doppler ultrasound

This is carried out to establish if there is arterial disease

Question 4

What is a normal ABPI score? What score signifies peripheral arterial disease? What score indicates critical limb ischaemia? Why can you get false positive with this?

Answer 4

Normal ABPI score 0.9-1.2

Score signifying peripheral arterial disease 0.5-0.9

Score indicating critical limb ischaemia <0.5

False positives can occur in limbs with severe astherosclerosis causing incompressible calcified arteries seen in eg diabetes mellitus

Question 5

What are the different causes of venous leg ulcers?

Answer 5

Varicose veins, DVT, chronic venous insufficiency, poor calf muscle function, obesity

Question 6

Chronic venous insufficiency is essentially a progressive disease increasing in severity if left untreated eventually leading to a venous ulcer forming Describe the progression in this disease?

Answer 6

Venous pressure increases due to backflow of flood leading to varicose veins–>oedema which causing damage to the blood vessels in the skin leading to the skin becoming inflamation and leaking of RBCs (extravasation of RBCs) (haemosiderin, eczema, lipodermatosclerosis)

Cannot heal well due to poor blood supply

Eventual ulcer formation

Question 7

In the management of venous ulcers, what investigations are carried out?

Answer 7

Clinical assessment of the ulcer is usually recommended - differentiating it from arteritic ulcer or diabetic

Wound swabs are not generally recommended - ONLY if ulcer increasingly painful/exudate/malodour/enlarging

Biopsy may be necessary if assessing for vasculitis or malignant change

Question 8

Why are wound swabs not generally recommended?

Answer 8

In the absence of clinical signs of infection (eg cellulitis, pyrexia, increased pain, rapid extension of area of ulceration, malodour, increased exudate), there is no indication for routine bacteriological swabbing of venous ulcers.

All ulcers will be colonised by micro-organisms at some point, and colonisation in itself is not associated with delayed healing.

Question 9

Management of ulcers can often prove to be difficult What is the usual recommended management?

Answer 9

It is important elevate the leg

Ulcer is initially cleaned with warm tap water and dried

A non-adherent dressing should then be used to cover the ulcer - and then wrapped with compression bandaging typically 4-layer compression bandaging is applied

Question 10

There is often slough formed from the venous ulcer What is slough? What can be used to treat it?

Answer 10

The slough is usually brown, grey or yellow in colour and is made from dead skin cells / bacteria

De sloughing agents may be necessary eg hydrogel/honey - creates moist environment rehydrating tissue

Sharp debridement can be used by experts with local anaesthetic

Surgery and larvae therapy are other options to treat the sloguh

Question 11

How does compression help in the treatment of the venous ulcer? Why does walking help?

Answer 11

Compression bandaging helps treat the ulcer as it reduces superficial venous pressure as it squeezes the vein helping to push the blood back to the heart

Walking also helps with the muscular pump to become more active and aid in venous return

Question 12

the 4 layer compression bandaging system uses graduaated compression Who should it be applied by? What is the pressure at the knee and ankle as measured by doppler?

Answer 12

Should be applied by a trained nurse

Pressure at ankle is 40mmHg and roughly 25mmHg below knee

Question 13

How often is the 4 layer bandaging system changed? When does it aim to heal the ulcers by?

Answer 13

The 4 layer bandaging system should be changed weekly or as required

Aims to heal ulcers within 12 weeks - if taking longer consider other causes eg malignancy

Question 14

What is the most common site for venous ulcers to appear? What are often cutaneous side effects due to venous ulcers?

Answer 14

Gaiter area is the most common area for the appearance of venous ulcers - medial aspect of the leg (near medial malleoulus)

Venous dermatitis (stasis eczema) and atrophie blanche (white scarring at the site of a previous healed ulcer)

Question 15

Which ulcers are superficial and which are deep? (arterial vs venous) What are risk factors for arterial ulcers?

Answer 15

Venous ulcers are usually superficial

Arterial ulcers are usually deep and more distal - risk factors PAD and diabetes

Question 16

Following leg ulcer healing, what should be worn as prophylaxis to prevent future ulcer re-occurence?

Answer 16

Compression stockings should be fitted and worn daily following leg ulcer healing or as prophylaxis in patients deemed at risk- usually indefinitely

Replacement stockings should be issued every 4-6 months

Question 17

Which drug have been shown to potentially be useful in the treating of chronic leg ulcers?

Answer 17

Aspirin and pentoxifylline

Pentoxifylline is believed to increase microcirculatory blood flow although the exact mechanism of action is unknown