Module 5 - Lower leg ulcers and neuro-ischaemic foot

Question 1

Types of Ulcers?

Answer 1

• Venous Ulcers
• Arterial Ulcers
• Mixed Venous / Arterial Ulcers
• Neuropathic
• Neuro-ischaemic

Question 2

Define an ulcer?

Answer 2

An ulcer is a loss of skin or mucosa integrity. The most common causes of leg ulcers are associated with vascular or neuropathic disorders and are referred to as:

Arterial - involving arteries and arterioles
Venous - involving veins and venules
Mixed arterial/venous - involving arteries, arterioles, veins and venules
neuropathic - due to loss of protective sensation

Question 3

Aetiology of venous ulcers

Answer 3

• Increased venous pressure
• increased permeability of capillaries
• leakage of fluid and macromolecules

leads to –>

venous stasis
valvular insufficiency

causing venous ulcers

Question 4

Aetiology of arterial leg ulcers

Answer 4

• Arterial insufficiency
• arteriolosclerosis
• Emboli

leads to –>

Peripheral arterial disease
Lower-extremity arterial disease
Peripheral vascular disease
Peripheral arterial occlusive
disease

Question 5

Explain neuropathic ulcers

Answer 5

loss of sensation - commonly on the foot

Question 6

Explain neuroischaemic ulcers

Answer 6

loss of sensation

loss of circulation

Question 7

Aims of treatment

Answer 7

• identify and treat precipitating cause
• promote circulation and improve venous return
• promote healing
• promote preventative care

Question 8

Essential guidelines for assessment of ulcers (page 133)

Answer 8

• Clinical History
• clinical examination
  - palpation of pedal and leg pulses
• hand held Doppler ultrasound
• ankle/brachial pressure index (ABPI)

Question 9

Predisposing factors of an arterial ulcer

Answer 9

• arteriosclerosis
• Advanced age
• Diabetes
• Hypertension
• Smoking

Question 10

Associated changes in the leg?

Answer 10

• Thin, shiny dry skin
• Absence of hair growth
• Thickened nails
• Pallor on elevation
• Limb may be cool

Question 11

Arterial ulcer locations

Answer 11

Over phalangeal heads
Between toes or at tip of toes
Above lateral malleolus
Over metatarsal heads
On side or sole of foot

Question 12

Arterial ulcer characteristics?

Answer 12

Well demarcated edges

pain at rest, relieved by lowering leg to a dependent position

Question 13

pain factor of arterial leg ulcer?

Answer 13

Exceedingly painful
Pain when legs elevated
Relieved by lowering legs
or walking

Question 14

surrounding skin of arterial leg ulcer?

Answer 14

May have neuropathy

Thin, shiny, hairless legs

Question 15

pedal pulse of an arterial ulcer?

Answer 15

Diminished or absent foot and leg pulses

Question 16

Predisposing factor of a venous ulcer?

Answer 16

• History of deep venous thrombosis
• Valvular incompetence in the perforating veins
• Obesity
• deficits in calf muscle pump

*chronic constipation (Joys thing)

Question 17

Associated changes in venous leg ulcers?

Answer 17

-Firm “brawny” oedema
haemosiderin (Reddish brown
pigmentation)
-Evidence of healed ulcers
-dilated and tortous superficial veins (Varicosities)
Warm leg
Hair on leg/toes

Question 18

Venous leg ulcers locations?

Answer 18

Anterior to medial malleolus
Pretibial area
Generally lower 1/3 leg
(gaiter area)

Question 19

Venous leg ulcer characteristics?

Answer 19

• uneven edges
• ruddy granulation tissue
• no necrotic tissue

Question 20

Pain factor for venous leg ulcer?

Answer 20

• moderate to no pain

- discomfort relieved by elevation of leg

Question 21

Venous ulcers surrounding skin?

Answer 21

Leaking oedema may result in maceration, pruritus and scale

Question 22

Venous ulcer pedal pulses

Answer 22

Normal foot and leg pulses

Question 23

General ulcer education/advice

Answer 23

Daily inspection
Skin hygiene
Moisturise skin
Stop smoking
Avoid trauma
Nutritious diet
Lose weight

Question 24

venous ulcer education for patient

Answer 24

• Regular ambulation
• Calf and foot muscle exercises
• Elevate feet when sitting(above heart level)
• Elevate foot of bed

Question 25

arterial ulcer education for patient

Answer 25

``` Avoid constrictive leg wear  Sit with legs down in neutral position  Elevate head of bed if night pain  Increase exercise as tolerated  Avoid trauma  Regular podiatry care  Avoid sudden temperature changes in feet ```

Question 26

Consultant investigation/interventions

Answer 26

- management of underlying disease - review of medications - duplex ultrasound - angiography/angioplasty - chemical or surgical sympathectomy - by-pass surgery - amputation

Question 27

Goal of treatment for arterial leg ulcers

Answer 27

-Pain management -Prevent infection -Healing if tissue perfusion adequate

Question 28

Goal of compression therapy

Answer 28

Improve calf muscle pump function Improve venous return Reduce venous hypertension Control venous oedema

Question 29

Types of bandages?

Answer 29

Short stretch: cotton without elastomers, extension 40-90%, low resting pressure Long stretch: contain elastomers, extension 90-140%, higher resting pressure Systems: a combination of short & long stretch multi-layers

Question 30

ABI <0.5

Answer 30

- arterial ulcer | - no compression

Question 31

ABI 0.5-0.7

Answer 31

Mixed arterial/venous ulcer - trial bandage according to tolerance - 20-30mm HG - light to moderate compression

Question 32

ABI 0.7-0.8

Answer 32

Mixed arterial/venous ulcer - trial bandage according to tolerance - 20-30mm HG - light to moderate compression

Question 33

ABI 0.8-1.2

Answer 33

venous ulcer trial bandage according to tolerance 30-40 mm Hg moderate to high compression

Question 34

ABI >1.2

Answer 34

possibly calcified vessels trial bandage according to tolerance 30-20mm Hg moderate to light compression' ***ARTERIAL CALCIFACTION CAN GIVE A FALSELY ELEVATED ABI (USUALLY >1.2) IN WHICH CASE COMPRESSION IS USED WITH EXTREME CAUTION -- SEEK FURTHER ADVISE _ sorry about the caps :)

Question 35

What are the pedal pulses do you palpate in a leg ulcer assessment?

Answer 35

dorsalis pedis pulse (on central dorsal part of the foot) - posterior tibial pulse (behind the medial malleolus) - peroneal pulse (lateral dorsal part of foot - popliteal pulse (behind the knee) - femoral pulse (in the groin)

Question 36

how do you measure a Ankle brachial pressure index?

Answer 36

lie down for 20-30 minutes - palpate pedal pulse s - record systolic BP for ankle and brachial SBP's ANKLE SBP ------------------- brachial SBP = ABI

Question 37

Assessments involved in Neuroischaemic exam

Answer 37

``` Doppler pressures (pedal pulses) Capillary refill test peripheral neuropathy (10 gram filament) ABI patellar and achillies tendon reflexes Duplex ultrasound Blood pathology FBC, Hb, CRP, BSL Rh factor. Angiography Venography Biopsy X ray ```

Question 38

Foot care and advise

Answer 38

``` Daily inspection Regular podiatry visits Early report of problems Wash feet daily Avoid extremes of temperature Wear shoes Moisturise but not between toes Cotton socks Buy shoes in afternoon & wear in gradually ```