Leg Ulceration

Question 1

What are the classifications of leg ulcers?

Answer 1

1. Ischaemic/arterial insufficiency aka peripheral arterial disease
2. Neuropathic
3. Stasis/venous
   Other:
   - Infective: syphilis, myco, osteomyelitis
   - Neoplastic: SCC, BCC, melanoma, Kaposi’s sarcoma
   - Systemic: pyoderma gangrenosum
   - Traumatic: thermal burns, bites, radiation

Question 2

Causes of neuropathic leg ulcers

Answer 2

• DM
• EtOH
• Spinal cord lesions
• Tabes dorsalis: untreated syphillis infection can lead to slow demylination of the dorsal column nerves
• Syringomyelia: cyst forms within on spinal cord

Question 3

Hx of ischaemic ulcers

Answer 3

Hx:

• V. painful
• Hx of claudication
• CV risk factors
• Previous peripheral vascular surgery

Question 4

Describe how an ischaemic ulcer appears on inspection

Answer 4

• Location: distal periphery, over dorsum of foot or pretibia
• Punch-out edges
• Ulcer base => poorly developed gray granulation tissue
• Surrounding skin is pale or mottled with no signs of inflammation
• Little bleeding when debrided

Question 5

Hx of neuropathic ulcers

Answer 5

• Painless

- Hx of Dm or other causes of neuropathy (DM, EtOH, spinal cord lesions, syringomyelia, tabes dorsalis

Question 6

Describe how an neuropathic ulcer appears on inspection

Answer 6

• Deep
• Location:
  a. pressure points or calluses
  b. plantar surface of MTP joints
  c. “Bunion” or “bunionette” areas
  d. Dorsum of IP joints
  e. Base of 5th MT
  f. MM or LM
  g. Callused posterior rim of heel pad
• features of distorted foot architecture:
  a. Hyperextension of MTP joints
  b. Hyperflexion of IP joints
  c. Charcot’s deformity

Question 7

List signs of neuropathy

Answer 7

• Hypoaesthesia
• proprioception
• 2-point discrimination
• Vibratory perception

Question 8

Hx of venous ulcers

Answer 8

• Hx of venous insufficiency: varicose veins, superfiicla thrombophlebitis or DVT, variceal bleeding
• Previous venous surgery

Question 9

Describe how an venous ulcer appears on inspection

Answer 9

• Larger and irregular edge
• Shallow
• Location: over gaiter area (commonly medial malleolus)
• Moist granulating base
• Surrounded by zone of inflammation and stasis dermatitis

Question 10

What are the associated signs of venous insufficiency (if suspecting venous ulcer)?

Answer 10

• varicose veins
• pitting oedema
• varicose eczema
• Pigmentation
• Lipodermatosclerosis (champagne leg)
• Atrophie blanche (white stellate scars)

Question 11

Compare the ulcers (arterial, venous, neuropathic) in SITE

Answer 11

1. Arterial
   distal at toe tips
   Pressure areas
2. Venous
   gaiter area

3. Neuropathic
dorsum of PIP / DIP
Plantar surface MTP
MM or LM
Heel
Other calloused areas

Question 12

Compare the ulcers (arterial, venous, neuropathic) in SIZE/SHAPE/DEPTH

Answer 12

1. Arterial
   small deep
2. Venous
   Large, irregular, shallow
3. Neuropathic
   Variable

Question 13

Compare the ulcers (arterial, venous, neuropathic) in BASE

Answer 13

1. Arterial
   pale and sloughy
2. Venous
   granulating
3. Neuropathic
   granulating

Question 14

Compare the ulcers (arterial, venous, neuropathic) in EDGES

Answer 14

1. Arterial
   punched out
2. Venous
   sloping and shallow
3. Neuropathic
   punched out

Question 15

Ix of leg ulcers

Answer 15

• FBE / U&E / CRP / glu / HbA1C / vasculitic screen / ESR / thrombophilic screen
• Swab m/c/s
• Xray ± bone scan ± MRI
• Duplex (arterial or venous)
• CTA
• DSA
• Biopsy

Question 16

Rx of leg ulcers

Answer 16

• Bed rest
• Elevation or dependency
• IV antibiotics
• Dressings
• Debridement / split skin graft
• Treat underlying aetiology
  a. Revascularisation
  b. Compression stockings / Varicose vein surgery
  c. Pressure offloading footwear / Total contact cast