Arterial ulcer

Question 1

Define arterial ulcers and summarise its aetiology and epidemiology

Answer 1

Definiton: A localized area of damage and breakdown of skin due to inadequate arterial blood supply. Usually seen on feet of patients with severe atheromatous narrowing of the arteries supplying the legs.

Aetiology:
- The ulcers are caused by a lack of blood to the capillary beds of the lower extremities

Risk Factors:

• Coronary heart disease
• History of stroke TIA
• Diabetes mellitus
• Peripheral arterial disease (e.g. intermittent claudication)
• Obesity and immobility

Epidemiology:

• 22% of all leg ulcers
• Prevalence increases with age and obesity

Question 2

Describe the history/presenting symptoms of arterial ulcers

Answer 2

• Often present distally at dorsum of foot or between toes
• Punched-out appearance
• Often elliptical with clearly defined edges
• The ulcer base contains grey, granulation tissue
• Night pain- hallmark of arterial ulcers
  • Pain is worse when supine (because arterial blood flow is further reduced when supine)
  • Pain is relieved by dangling affected leg off the end of the bed

Question 3

What are the signs of arterial ulcers upon physical examination?

Answer 3

• Night pain
• Punched-out appearance
• Hairlessness
• Pale skin
• Absent pulses
• Nail dystrophy
• Wasting of calf muscles

Question 4

What investigations are used to identify arterial ulcers?

Answer 4

• Duplex ultrasonography of lower limbs- assess patency of arteries and potential for revascularisation or bypass surgery
• ABPI
• Percutaneous angiography
• ECG
• Fasting serum lipids, fasting blood glucose and HbA1c (diabetes is a major risk factor)
• FBC- anaemia can worsen the ischaemia