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Flashcards in Leg Ulcer Deck (33):
1

List a differential diagnosis of leg ulcers.

Venous ulcers
Mixed ulcers
Arterial ulcers
Neuropathic ulcers
Pressure ulcers
Lymphoedema ulcers
Traumatic ulcers
Vasculitic ulcers
Marjolin’s ulcers

2

What type are the majority of leg ulcers?

Venous ulcers – 70%

3

List two key features of the ulcer history.

Is the ulcer painful?
How long has the ulcer been there?

4

What is a Marjolin’s ulcer?

A squamous cell carcinoma arising from chronically inflamed tissue

5

How does the pain differ in:
Venous Ulcers
Arterial Ulcers
Neuropathic Ulcers
Pressure Ulcers

- Venous Ulcers
Not particularly painful
Pain is relieved when the leg is elevated (because pain/ulcer is caused by venous stasis)
- Arterial Ulcers
Quite painful
Pain is worse when the leg is elevated (because pain is due to ischaemia)
- Neuropathic Ulcers
NO pain
- Pressure Ulcers
Exquisitely tender
Not necessarily painful

6

How does the time of presentation of ulcers differ in:
Venous Ulcers
Arterial Ulcers
Neuropathic Ulcers
Pressure Ulcers
Marjolin Ulcers

- Venous Ulcers
Present late because they aren’t that painful
Tend to have long, recurring history
- Arterial Ulcers
Present early because they are painful
Often present secondary to trivial trauma
- Neuropathic Ulcers
Present late because they are not painful
- Pressure Ulcers
Can develop surprisingly fast (especially in hospital because of bed rest)
- Marjolin Ulcers
Long-history of an ulcer/chronic skin inflammation that has suddenly changed

7

List some key associated features of:
Venous Ulcers
Arterial Ulcers
Neuropathic Ulcers

- Venous Ulcers
Varicose veins
Skin changes: haemosiderin deposition, stasis dermatitis, lipodermatosclerosis
Ankle oedema
- Arterial Ulcers
Peripheral vascular disease (e.g. claudication, night pain, rest pain)
Coronary artery disease (e.g. angina, SOBOE)
Cerebrovascular disease (e.g. stroke, TIA)
- Neuropathic Ulcers
Sensory loss
Unstable gait
Infected ulcers (mainly in diabetics)

8

List risk factors for:
Venous Ulcers
Arterial Ulcers
Neuropathic Ulcers
Pressure Ulcers

- Venous Ulcers
Presence of varicose veins
Immobility
Malnourishment
Recurrent DVTs
Pelvic mass compressing iliac veins
AV malformations
Major joint replacement (carries high subclinical DVT risk)
- Arterial Ulcers
Atherosclerosis risk factors: hypertension, diabetes, smoking, hypercholesterolaemia etc.
- Neuropathic Ulcers
Diabetes mellitus
Alcohol abuse
- Pressure Ulcers
Long-term bed rest/ long lie

9

Describe the common sites of the following types of ulcer:
Venous Ulcers
Arterial Ulcers
Neuropathic Ulcers
Pressure Ulcers

- Venous Ulcers
Gaiter area of the legs (mainly above the medial malleolus)
This is where venous pressure is highest
- Arterial Ulcers
Distal areas (e.g. between the toes) and frequently compressed areas (e.g. ball of foot)
- Neuropathic Ulcers
Pressure areas (e.g. ball of foot) – because it is subject to repetitive trauma
- Pressure Ulcers
Bony prominences that experience constant pressure (e.g. heel)

10

Describe the characteristics of:
Venous Ulcers
Arterial Ulcers
Neuropathic Ulcers

- Venous Ulcers
Shallow
Wet
Irregular borders that look white and fragile
- Arterial Ulcers
Deep
Dry
Punched-out appearance
Often elliptical
- Neuropathic Ulcers
Thick, keratinized raised edges surrounding the ulcer

11

Which diseases are associated with pyoderma gangrenosum?

Inflammatory bowel disease
Blood dyscrasias (e.g. multiple myeloma)

12

Describe the typical appearance of pyoderma gangrenosum.

An ulcer with a characteristic purple halo around it

13

Venous ulcers can scar leading to white patches of scarred skin. What is this feature called?

Atrophie blanche

14

What is the term used to describe severe lipodermatosclerosis?

Inverted champagne bottle sign

15

Describe some features of the affected limb in a patient with arterial ulcers.

Cold
Pale
Absent/weak pulses
Delayed capillary refill time
Atrophic skin changes (dry, shiny, hairless)

16

What is Buerger’s test? Describe how it is performed and what a positive result indicates.

Whilst the patient is supine, raise the leg up until it goes pale
NOTE: in normal people, the leg should remain pink even at 90 degrees
The angle at which it goes pale is ‘Buerger’s angle’
Then the leg is put back down
With positive Buerger’s sign – the leg will slowly turn pink but then it will go red (this is due to reactive hyperaemia)

17

Describe some features of the affected limb in a patient with neuropathic ulcers.

Loss of sensation (gloves and stockings distribution)
Foot deformities (e.g. Charcot foot)

18

Why would you check FBC in a patient with ulcers?

Anaemia could worsen the ischaemia that causes ulcers

19

List some other investigations that you would use in a patient with a suspected venous ulcer.

Fasting lipids
Capillary glucose
Urinalysis
Venous duplex ultrasound – good for assessing saphenofemoral competence
ABPI

20

Why is it important to calculate the ankle-brachial pressure index (ABPI) before treating an ulcer?

This allows assessment of arterial disease
ABPI < 0.8 – do NOT apply pressure bandage because it will worsen the ischaemia

21

Which ulcers may require a biopsy?

Marjolin’s ulcer

22

Outline the management of venous ulcers.

Adequate nutrition
Leg elevation
Compression bandages
Elastic stockings
Varicose vein surgery

23

Define critical limb ischaemia.

Severe obstruction of the arteries which markedly reduces blood flow to the extremities and has progressed to the point of causing severe pain, ulcers or gangrene. These patients will have rest pain.

24

List some investigations for suspected arterial ulcers.

Duplex ultrasonography – assess arterial patency
Percutaneous angiography
ECG
Fasting lipids, glucose, HbA1c
FBC

25

Outline the management of arterial ulcers.

Dress the ulcer to prevent infection
Analgesia
Antibiotics (if signs of infection)

26

List some surgical options for treating arterial ulcers.

Angioplasty
Bypass surgery
Amputation

27

What causes acute limb ischaemia?

A sudden lack of blood flow to a limb

28

What are the signs of acute limb ischaemia?

6 Ps of acute limb ischaemia:
Pale
Pulseless
Painful
Paralysis
Paraesthesia
Perishingly cold

29

List some possible interventions for acute limb ischaemia.

Embolectomy
Percutaneous thrombolysis
Revascularisation angioplasty
Bypass surgery
Amputation

30

Outline the treatment of neuropathic ulcers.

Foot care
Manage diabetes
Debridement of necrotic tissue
Treat infections

31

What is a major complication of neuropathic ulcers?

Osteomyelitis

32

Outline the management of pressure ulcers.

Record the ulcer
Relieve the ulcer
Reduce further ulcers
Reassess ulcer

33

List some surgical options for varicose veins.

Avulsion/phlebectomy
Stripping
Injection sclerotherapy
Radiofrequency ablation