What are the different types of lower limb ulcers?
- Venous, Arterial, Neuropathic
- Most lower limb ulcers have venous origin
- Can also be caused by trauma, vasculitis, SCC malignancy
- Can also be a pressure sore (prolonged excessive pressure over a bony prominence)
How are pressure ulcers managed in hospital generally?
- Adequate mattress
- Repositioning
- Good wound management
What is the pathophysiology of a venous ulcer?
- Due to venous insufficiency
- Shallow with irregular borders and a granulating base and often found over medial malleolus. Prone to infection and cellulitis
- Due to valvular incompetence so impaired venous return with resultant venous hypertension. Trapping of WBC in capillaries and formation of fibrin cuff around vesel hindering oxygen transport to tissue
- WBC also release inflammatory mediators so tissue injury, poor healing and necrosis
What are some risk factors for developing a venous ulcer?
- Increasing age
- Pre exiting venous incompetence (e.g varicose veins) or previous DVT
- Pregnancy
- Obesity
- Severe leg injury
What are the clinical features of a venous ulcer and how do you investigate them?
Features:
- Painful with aching, itching or burning before ulcer appears
- May have varicose veins and ankle oedema
- May have varicose eczema, thrombophlebitis, haemosiderin skin staining, lipodermatosclerosis or atrophie blanche
Ix:
- Clinical
- Do Doppler US to confirm venous insufficiency, usually at saphenofemoral or saphenopopliteal junction
- Ankle Brachial Pressure index to assess arterial component to see if compression therapy would help
- Take swab cultures if infection
- Consider thrombophilia or vasculitic screening in younger patients
How are venous ulcers managed?
Conservative
- Leg elevation and increased exercise to promote calf pump
- Lifestyle changes e.g weight loss, improved nutrition
- Abx if swabs so infection
Definitive
- Multicomponent compression bandaging changed one or twice a week for about 6/12. Need ABPI to be >0.8 before any bandaging applied
- Use emollients to keep skin intact
- If concurrent varicose veins treat with endovenous techniques or open surgery as improving venous return helps heal ulcers
What are the risk factors for developing an arterial ulcer?
Reduction in arterial blood flow so decreased perfusion of tissues.
Same risk factors for peripheral arterial disease:
- Smoking
- DM
- HTN
- Hyperlipidaemia
- Increasing age
- Obesity
- Inactivity
What are the clinical features of an arterial ulcer?
- Small deep lesions with well defined borders and a necrotic base with no granulation tissue
- Found at pressure points and sites of trauma
- Preceding history of intermittent claudication (pain on walking) or critical limb ischaemia (pain at night)
- Limbs often cold and pulseless but sensation maintained
- Often have limb hair loss
How are arterial ulcers investigated and managed?
Ix
- Do ankle brachial pressure index to quantify extent of any peripheral arterial disease. (>0.9 normal, <0.5 severe)
- Can do duplex US, CT angiography or MRA to find location of arterial disease
Mx
- Urgent vasculat review
- Conservative: lifestyle changes like weight loss, stop smoking, increase exercise
- Medical: statin, antiplatelet (aspirin or clopidogrel) and optimise BP and glucose
- Surgical: angioplasty or bypass grafting if extensive
What are the risk factors for neuropathic ulcers?
Anything that causes peripheral neuropathy:
- B12 Deficiency
- Diabetes
These can precipitate:
- Any foot deformity
- Any peripheral vascular disease
What are the clinical features of a neuropathic ulcer?
- Painless as loss of peripheral neuropathy so repetitive stress and unnoticed injuries have no protective mechanism so form ulcers at pressure points
- History of peripheral neuropathy e.g glove and stocking distribution with warm feet and good pulses
- May have burning/tingling in legs (painful neuropathy) or amotrophic neuropathy (painful wasting of proximal quads)
Whar investigations should you do with a neuropathic ulcer?
- Blood glucose levels (either BM or HbA1c)
- Serum B12
- ABPI +/- duplex to look for arterial disease
- Swab if evidence of infection
- If signs of deep infection (e.g visible bone) do X-Ray to look for osteomyelitis
- Assess extent of neuropathy with 10g monifilament and 128Hz tuning fork
How are neuropathic ulcers managed?
Refer to Diabetic Foot Clinic
- Optimise diabetic control (HbA1c <7%)
- Improved diet and exercise
- Regular chiropody for foot hygeine
- Appropriate footwear
- Any signs of infection take swabs and give flucloxacillin (gram +ve cover)
- If ischaemic or necrotic may need surgical debridement or amputation
What is Charcot’s foot?
