Venous ulcers (CV)

Question 1

What are venous ulcers?

Answer 1

Large, shallow, sometimes painful ulcers usually found superior to the medial malleoli

Break in skin below knee which has not healed within 2 weeks, occurring in presence of venous disease

Question 2

What are venous ulcers caused by?

Answer 2

• incompetent valves in lower limbs leading to venous stasis and ulceration
• sustained venous hypertension
• results from chronic venous insufficiency (venous stasis) due to:
  1. venous valve incompetence
  2. impaired calf muscle pump

Question 3

What are the clinical features of venous ulcers? (4)

Answer 3

• frequently occur just above the medial malleolus
• typically painless/mild pain - less painful when elevated
• shallow ulcers with irregular borders
• itchy

Question 4

What might you see on examination of venous ulcers? (7)

Answer 4

• phlebitis
• lipodermatosclerosis - painful hardened right skin, inverted champagne bottle sign if severe
• haemosiderin deposition - dark colour
• excessive exudate
• pitting oedema - rule out CKD, heart failure
• venous eczema - itchy, red, scaly and/or flaky skin, may have blisters, crust on surface
• atrophie blanche - star-shaped, ivory-white, depressed, atrophic scars with surrounding pigmentation

Question 5

What are some features of venous insufficiency (therefore seen in venous ulcers)? (4)

Answer 5

• oedema (pitting)
• brown pigmentation - haemosiderin deposition
• lipodermatosclerosis - hardening of skin
• eczema

Question 6

What are some risk factors for venous ulcers? (7)

Answer 6

• obesity
• immobility
• increasing age
• varicose veins
• history of DVT
• previous injury to leg
• abdominal tumours - compressing iliac veins, AV malformations, major joint replacement

Question 7

What are the first-line investigations for venous ulcers? (2)

Answer 7

• duplex ultrasound of lower limbs
• ankle brachial pressure index (ABPI) - to exclude arterial ulcer, normal range 0.8-1.3

Question 8

For venous ulcers, what do we do if ankle bronchial pressure index (ABPI) <0.8?

Answer 8

Do NOT apply a pressure bandage as this could worsen the ulcer

Question 9

When is biopsy performed for venous ulcer?

Answer 9

In any non-ischaemic wound that fails to improve after 3 months of treatment - if possibility of Marjolin’s ulcer

Question 10

When are swabs for microbiology done for venous ulcer?

Answer 10

If signs of infection

Question 11

What blood abnormalities can delay healing of venous ulcers?

Answer 11

• FBC - presence of anaemia
• U&Es - high urea = dehydration
• low albumin = protein loss and malnutrition

Question 12

How can we monitor progression of venous ulcers?

Answer 12

Measure surface area of ulcer to allow monitoring of progression

Question 13

What are some differential diagnoses for venous ulcers? (6)

Answer 13

• peripheral artery disease
• rheumatoid arthritis (vasculitic)
• systemic vasculitis
• diabetes mellitus
• malignancy
• pressure ulcers etc

Question 14

Describe the management plan for venous ulcers. (10)

Answer 14

• compression bandaging - to reduce venous stasis
• debridement and cleaning
• skin graft if large / refractory ulcers
• antibiotics if infected
• topical steroids to help with surrounding dermatitis
• pentoxifylline (peripheral vasodilator)
• adequate nutrition
• lifestyle modification - mobilise to encourage venous flow in legs
• leg elevation - reduce BP in LL
• varicose vein surgery - prevent recurrence if ulcer caused by obvious superficial varicosities and no deep vein incompetence

Question 15

When is compression bandaging contraindicated in venous ulcers?

Answer 15

In arterial disease, hence do ABPI beforehand to rule out arterial insufficiency (i.e. if ABPI<0.8 do not use compression bandaging)

Question 16

When is referral considered for venous ulcers?

Answer 16

• diagnostic uncertainty
• ulcer rapidly deteriorating or has an atypical location/appearance
• arterial or mixed venous/arterial disease
• DM, RA or systemic vasculitis, malignancy
• poor ankle mobility
• suspected iliac vein stenosis

Question 17

What are some complications of venous ulcers? (2)

Answer 17

• recurrence (below-knee graduated compression stockings help)
• infection

Question 18

Describe the prognosis of venous ulcers.

Answer 18

Good - results are better if patients are mobile with few comorbidities