lower limb ulcers Flashcards
what are ulcers?
abnormal breaks in the skin or mucous membranes.
what is venous ulcers like?
Venous ulcers are shallow ulcers with a granulated base, often with other clinical features of venous insufficiency present. Usually on medial malleolus
caused by venous insufficiency
most lower limb ulcers have a venous origin
what are the properties of neuropathic ulcers?
result of peripheral neuropathy
loss of protective sensation
= repetitive stress and unnoticed injuries =
painless ulcers over areas of abnormal pressure, often secondary to joint deformity in diabetics
what are the properties of arterial ulcers?
Arterial ulcers are found at distal sites, often with well-defined borders and other evidence of arterial insufficiency
caused as a result of reduced arterial blood flow
most commonly occur distally at sites of trauma and in pressure areas (e.g the heel).
what are pressure ulcers?
in patients who are less mobile, ulcers may also be caused by prolonged or excessive pressure over a bony prominence, leading to skin breakdown and eventual necrosis.
what can cause impaired venous return, causing venous ulcers?
valvular incompetence or venous outflow obstruction leads to impaired venous return
the resultant venous hypertension causes the “trapping” of white blood cells in capillaries and the formation of a fibrin cuff around the vessel
this hinders oxygen transportations to tissue
WBC also become activated, releasing inflammatory mediators causing tissue injury, poor healing and necrosis
what are the risk factors for venous ulcers?
- increasing age
- pre existing venous incompetence/ history of venous thromboembolism and varicose veins
- pregnancy
- obesity/physical inactivity
- severe leg injury/trauma
what are the clinical features of venous ulcers?
- typically shallow with a granulating base and irregular borders
- painful at end of day
- in gaiter region of legs
- symptoms of chronic venous disease e.g aching, itching, bursting sensation present, often before ulcer appears
- may be ankle or leg oedema
- features associated with venous insufficiency e.g varicose eczema, thrombophlebitis,
what investigations are done into venous ulcers?
clinical, with venous insufficiency confirmed with duplex ultrasound
Ankle brachial pressure index is needed to asses for any arterial component to the ulcers/ to see if compression therapy is useful
if infection is suspected, take swab cultures
do a thrombophilia and vasculitic screen if there is a FH of prothrombotic and autoimmune disease
what are the risk factors for arterial ulcers?
risk factors are the same as those for peripheral arterial disease
- smoking
- DM
- hypertension
- hyperlipidaemia
- increasing age
- positive family history
- obesity
- physical inactivity
what are the clinical features of arterial ulcers?
- intermittent claudication
- critical limb ischaemia (pain at night caused by reduced blood flow to peripheries)
- develops over long period of time with little/no healing
- painful
- cold limbs
- thickened nails
- necrotic toes
- hair loss
- reduced/ absent pulses in limb
- sensation is maintained in pure arterial ulcers
- asses for signs of venous insufficiency as may be mixed pathology
what investigations are done into arterial ulcers?
Ankle brachial pressure index (ABPI) to quantify extent of peripheral arterial disease
can also do clinical examination for location of arterial disease followed by imaging including duplex USS, CT angiography and/or Magnetic resonance angiogram (MRA)
how are arterial ulcers managed?
conservatively
- lifestyle changes e.g smoking cessation, weight loss and exercise
- medical e.g CV risk factor modification like statins, anti platelet agent (clopidogrel and aspire) and BP and Glucose optimisation.
- surgical e.g angioplasty or bypass grafting for more extensive disease. Non healing ulcers may be offered skin reconstruction with grafts.
what are the risk factors for neuropathic ulcers?
can develop with any condition with peripheral neuropathy, commonly DM and B12 deficiency
risk is furthered by foot deformities or concurrent peripheral vascular disease
what are the clinical features of neuropathic ulcers?
history of peripheral neuropathy or symptoms of peripheral vascular disease
clinical manifestations of neuropathy include
- burning/tingling in legs
- single nerve involvement
- amyotrophic neuropathy (painful wasting of proximal quadriceps)
- occur most commonly on sites of pressure on feet e.g heels
- may be peripheral neuropathy in glove and stockingg distribution, with warm feet and good pulses (unless element of concurrent arterial disease)
