Ulcers

Question 1

What causes venous ulcers

Answer 1

Venous hypertension due to insufficiency
Incompetence valves caused by varicose veins / DVT
Leads to oedema

Question 2

What are other RF

Answer 2

Immobility
Malnourishment
Recent major joint replacement

Question 3

What are symptoms

Answer 3

Asymptomatic
General discomfort / ach
Often painful 
Worse during the day / prolonged standing
Relieved raising the leg 
Itchy skin

Question 4

What area

Answer 4

Common in gaiter region

Common in malleolar (medial > lateral)

Question 5

What is seen O/E

Answer 5

Large shallow irregular ulcer 
Exudative
Red / pink granulation tissue
Yellow slough
Pitting oedema = 1st sign
Venous eczema
Haemosiderin staining 
Varicose veins
Present pulses + warm skin

Question 6

What is risk of venous ulcer

Answer 6

Develop into Marjolin’s ulcer

Irregular, raised, foul smelling

Question 7

What is needed

Answer 7

Inspection
Lavage
Wide excision of necrotic and malignant tissue

Question 8

How do you investigate venous ulcers

Answer 8

ABPI to ensure not arterial - will be normal

Venous duplex to look for reflux / thrombosis and asses function

Question 9

How do you manage

Answer 9

Principles of wound management 
- Inspection
- Remove devitalised
- Dressing 
Must treat underlying cause
May need Ax if infection 
Possible surgery for various veins

Question 10

What do you do for oedema

Answer 10

Compression bandaging
Elevation
Rarely diuretics

Question 11

What causes arterial ulcers

Answer 11

Insufficient arterial supply 
PVD
Smoking
Age
DM
Hypertension
Hyperlipid

Question 12

What are symptoms

Answer 12

Critical ischaemia pain
Get pain at rest
Worse lying flat
Releived by standing or hanging feet over bed

Question 13

What are signs on examination

Answer 13

Small sharply defined deep ulcer 
PAINFUL 
Necortic base 
Well demarcated 
Pale and dry
Little granulation
May see necrosis 
Hair loss
Cold skin 
Prolonged CRT
Absent pulses
Shiny pale skin
Loss of hair

Question 14

What is Buerger

Answer 14

Elevate foot up to 30 degrees
Leads to colour fading and pain
When hang foot over bed then becomes deep red as fills with blood

Question 15

How do you investigate

Answer 15

ABPI
Dupplex USS + angio
Percutaenous USS

Question 16

How do you Rx

Answer 16

Basic wound
RF modification
Angioplasty or stent
Surgery - bypass or amputation

Question 17

What causes diabetic foot ulcers

Answer 17

Hyperglycaemia = neuropathy and PVD
Autonomic = dry cracked skin
Motor = foot drop / deformity

Question 18

What are symptoms

Answer 18

Sensory loss so ulcer are not painful
Foul smell if infected
Sx of poor glycemic control

Question 19

What is seen O/E

Answer 19

Typically plantar
Thickened surrounding skin
Infection

Question 20

What is common cause of amputation

Answer 20

Infection

Question 21

How do you prevent

Answer 21

Education 
BG control
Self foot care - examine regular, footwear, toenail care 
Identify RF
Regular foot review

Question 22

How do you Rx

Answer 22

Basic wound
Minimise neuropathy
Treat ischaemia - same as arterial

Question 23

How do you minimise neuropathy

Answer 23

Offloading
Custom footwear
Resection of wound / bony deformity

Question 24

What are pressure sores

Answer 24

Breakdown of skin and underlying tissue 2 to unrelieved pressure or friction

Question 25

Where are common sites

Answer 25

Sacrum Ischial tubersoity Greater trochanter of femur Heels

Question 26

What are RF

Answer 26

``` Immobile Incontinence Poor nutrition Poor sensation Age ```

Question 27

Stage 1

Answer 27

Non-blanching erythema Red, warm, painful oedema Skin intact

Question 28

Stage 2

Answer 28

Partial loss of epidermis or dermis Often shallow ulcer with red / pink wound bed No slough

Question 29

Stage 3

Answer 29

Full thickness loss | Subcutaneous involvement

Question 30

Stage 4

Answer 30

Full thickness loss | Involvement of muscle / bone / tendon

Question 31

What does stage 4 have high risk of

Answer 31

OM

Question 32

How do you prevent

Answer 32

Risk assess WATERLOW Air mattress Pressure relief

Question 33

How do you Rx

Answer 33

``` Basic wound management Plastic surgeon for skin graft Nutrition Mobilisation Support surfaces / mattress ```

Question 34

What is typical history of neuropathic ulcer

Answer 34

Often painless Abnormal sensation Hx DM / neuro disease

Question 35

What is ulcer like

Answer 35

``` Common on pressure sites - Heel / toes / metatarsals Variable size and depth Maybe surrounded by hyperkeratotic lesion e.g. callus Warm skin Normal pulses Peripheral neuropahty ```

Question 36

What are possible investigations

Answer 36

ABPI If <0.8 implies neuroischaemic ulcer common in DM X-ray to exclude OM

Question 37

How do you manage

Answer 37

Wound debridement Regular repositioning Appropriate footwear Good nutrition

Question 38

What are other types of ulcer

Answer 38

Vasculitic- purpuric and punched out Infected - dischagrge + systemic unwell Malignancy - SCC on background of chronic inflammation / non-healing ulcer