Vascular: Leg Ulcers

Question 1

Define the term ‘ulcer’.

Answer 1

Breach in continuity of skin, epithelium or mucous membrane, caused by sloughing out of inflamed necrotic tissue.

Question 2

What are the 4 most common diagnoses for leg ulcers?

Answer 2

1. Venous ulcer
2. Arterial (atherosclerotic) ulcer
3. Mixed arterial/venous ulcer
4. Neuropathic ulcer

Question 3

where are each of the 3 main types of ulcer more commonly found?

Answer 3

Venous: where venous pressures are highest - gaiter area, esp. medial. Most common area is just above medial malleolus as is site of medial calf perforators.

Arterial: where arterial supply is worst (distal areas) and those frequently compressed - ball of foot, between toes, tips of toes, lateral malleolus.

Neuropathic: pressure areas of foot where foot rubs on poorly-fitting footwear (e.g. beneath metatarsal heads)

Question 4

describe the appearance of the 3 main types of ulcer

Answer 4

Venous:

• irregular, sloping white edges
• shallow and wet

Arterial:

• well-defined, punched-out edges (often elliptical)
• deep and dry

Neuropathic:
- very thick, keratinised raised callous edges

Question 5

which Ix would you perform on someone with an ulcer?

Answer 5

Bloods:

• FBC: ?infection, ?anaemia
• ESR or CRP: ?vasculitis
• albumin: ?malnutrition
• fasting lipids: ?hyperlipidaemia (contributing to any atherosclerosis)
• glucose: ?diabetes

Bedside tests:

• urinalysis: look for glucose (?DM) and haematuria/proteinuria (?vasculitis)
• duplex USS: to assess competence of sapheno-femoral and sapheno-popliteal junctions, and state of perforators and deep venous system
• ankle-brachial pressure index (ABPI): to assess for arterial disease (perform even if convinced ulcer is venous as if ABPI <0.8, pt must not have pressure bandage applied, may be mixed ulcer)

Question 6

how would you interpret various ABPI results?

Answer 6

ABPI 1 = normal

ABPI 0.5-0.8 = arterial disease, requires referral to vascular clinic for further assessment

ABPI <0.5 = arterial ulcers, compression treatment contraindicated. Requires referral to vascular clinic for further assessment and possible revascularisation.

Question 7

how would you manage a pt with venous ulcers?

Answer 7

1. Lifestyle modification: adequate nutrition (improve healing) and mobilisation (encourage blood flow)
2. Leg elevation whenever possible (reduce BP in legs)
3. Compression bandages applied and frequently changed (reduce pooling of blood in lower limbs)

Question 8

how can venous ulcer recurrence be prevented once they are healed?

Answer 8

• graduated class I or II elastic stockings

- varicose vein surgery if ulcer caused by obvious superficial varicosities and there is no deep vein incompetence

Question 9

how would you manage a pt with arterial ulcers?

Answer 9

Involves Mx of pts with critical limb ischaemia:

1. lifestyle modification: smoking cessation, weight loss, increased exercise
2. statin therapy (reduce hyperlipidaemia)
3. antiplatelet agent (e.g. aspirin or clopidogrel) (reduce risk of blood clots)
4. BP optimisation via antihypertensive therapy
5. surgery in severe cases: angioplasty (with or without stenting) or bypass grafting

Question 10

how would you manage a pt with neuropathic ulcers?

Answer 10

1. regular dressings
2. optimisation of diabetic control - aim for HbA1c <7%
3. regular chiropody to maintain good foot hygiene and appropriate footwear
4. if signs of infection: swabs and antibiotics (e.g. flucloxacillin)
5. ischaemic or necrotic tissue may require surgical debridement or amputation