Limb Ulceration and Gangrene - Arterial and Venous Ulcers

Question 1

What are leg ulcers?

Answer 1

Wounds or breaks in the skin that do not heal or heal slowly, due to underlying pathology. They have the potential to get progressively larger and become more difficult to deal with.

Question 2

What are the 4 commonest types of ulcers?

Answer 2

1. Venous Ulcers (80%).
2. Arterial Ulcers.
3. Diabetic Foot Ulcers.
4. Pressure Ulcers.

Question 3

What is a mixed ulcer?

Answer 3

A combination of arterial and venous disease causing the ulcer.

Question 4

What is Marjolin’s Ulcer?

Answer 4

A SCC that occurs at sites of chronic inflammation e.g. burns, osteomyelitis after 10-20 years that mainly occurs on the lower limb.

Question 5

What is Pyoderma Gangrenosum?

Answer 5

Erythematous nodules or pustules which ulcerate that can occur at stoma sites, associated with IBD and RA.

Question 6

Give 6 differences between Arterial and Venous Ulcers.

Answer 6

1. SITE : A = Distally - Toes, Dorsum of Foot.
   V = Gaiter Area (between medial malleolus and bottom of calf).
2. ASSOCIATIONS : A = PAD. V = Chronic Venous Insufficiency.
3. SIZE : A = Smaller and Deeper. V = Larger and More Superficial.
4. SHAPE : A = Well-defined borders and ‘punched-out appearance’. V = Irregular and gently sloping borders.
5. SYMPTOMS : A = less likely to bleed but painful when flat or elevated leg. V = Less painful but relieved by elevated and more likely to bleed.
6. EPIDEMIOLOGY - A = Elderly Men. V = Middle-Aged Women.

Question 7

What do arterial ulcers result from?

Answer 7

Insufficient blood supply to the skin due to PAD.

Question 8

What do venous ulcers result from? (2)

Answer 8

1. Pooling of blood and waste products in the skin, secondary to chronic venous insufficiency (venous hypertension).
2. Other causes : calf-pump dysfunction and neuromuscular disorders.

Question 9

Give 5 other features of chronic venous insufficiency.

Answer 9

1. Oedema.
2. Brown Hyperpigmentation (haemosiderin deposition).
3. Liopdermatosclerosis.
4. Eczema.
5. Atrophic Blanche.

Question 10

Give 6 risk factors for venous ulcer disease.

Answer 10

1. Obesity.
2. Immobility.
3. Varicose Veins.
4. Previous DVTs.
5. Age.
6. Previous Trauma to Leg.

Question 11

Pathophysiology of Venous Ulcers (5).

Answer 11

1. Valvular Incompetence/Venous Outflow Obstruction.
2. Impaired Venous Return and trapping of WBCs in capillaries.
3. Fibrin cuff around the vessel - hinders Oxygen transportation into tissue.
4. WBCs activated with release of inflammatory mediators.
5. Tissue injury, poor healing, necrosis.

Question 12

Investigations of Arterial/Venous Ulcers.

Answer 12

1. ABPI (to either exclude or include PAD) always.

2. Arterial - ABPI/Doppler US. Venous - Clinical (after excluding arterial).

Question 13

Why is a Doppler Ultrasound useful?

Answer 13

Look for the presence of reflux.

Question 14

Why is a Duplex Ultrasound useful?

Answer 14

Anatomy and flow of the vein.

Question 15

Management of Arterial Ulcers.

Answer 15

Same as management of Peripheral Arterial Disease - urgent referral to vascular team to consider vascularisation.

Question 16

Management of Venous Ulcers.

Answer 16

1. Lifestyle Advice.
2. Emollient Treatment of Leg.
3. Compression Bandaging.
4. Pentoxifylline.
5. Surgery (Debridement - Skin Grafting).

Question 17

What does good wound care of venous ulcers involve? (3)

Answer 17

1. Cleaning wound.
2. Debridement (removing dead tissue).
3. Dressing the wound.

Question 18

Compression Bandaging (2).

Answer 18

1. Treat venous ulcers after arterial disease is excluded.

2. 4 layers changed once or twice every week.

Question 19

What is Pentoxifylline?

Answer 19

Orally taken medication to improve healing (peripheral vasodilator) - not licensed.

Question 20

When is skin grafting required?

Answer 20

If the venous ulcer fails to heal after 12 weeks or it is larger than 10cm2.

Question 21

Complications of Venous Ulcers (4).

Answer 21

1. Immobility (due to pain).
2. Infection & Sepsis.
3. Osteomyelitis.
4. Decreased Quality of Life.