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Leg Ulcers |
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This is from a Leg Ulcer Workshop lecture at Royal North Shore hospital
Chronic Non Healing wounds of the lower leg
Four Facts about Legs ulcers that can be stated without fear of contradiction 1. They are Common 2. Treatment is time consuming 3. They are not life threatening 4. Most Doctors would prefer someone else to be looking after them
Principals of Leg Ulcer Management 1. Determine the cause of the ulceration 2. Control the factors affecting wound healing 3. Select an appropriate moist wound dressing 4. Plan for wound maintenance
Basic Evaluation of patients with chronic non healing wounds of the lower leg
History •Complete medical history and examination. •Ulcer specific history –Number –Location –Duration –Prior treatments –Course of treatment •History should note lower limb pain , paraesthesia , anaesthesia , claudication DVT, Cellulitis, Limb or pelvic surgery, Trauma, Diabetes Thyroid disease, IHD, Hyperlipidemia, HT, CVA, Neurologic disease, Gastrointestinal, Rheumatological Alcohol abuse, Tobacco and Skin disorders
Examination
–Ulcer specific –location and size of each ulcer –base necrotic , granulation tissue,tendons –Magnitude and odour of exudate –tracing or digital photography monthly –Perilesional –erythema –induration –maceration –dryness –scaling –Cellulitis –previous scars –atrophie blanche –gangrenous digits –clubbing –cyanosis –varicose veins –livedo reticularis –hyperpigmentation –dermatitis –lipodermatosclerosis
Palpation of pulses –AB INDEX by hand held Doppler –Monofilament test in diabetic patients
Other tests
–Pathology –All FBC C-reactive protein, creatinine BSL Albumin –Some RF ,ANF ,Thrombophilia tests, Chol/TG –Occasional Wound swab –Rarely Biopsy to exclude malignancy , SCC ,BCC, Mycosis Fungoides, Vasculitis, Pyoderma Gangrenosum, Necrobiosis Lipoidica Diabeticorum Atypical Infections
Radiology Exclude underlying osteomyelitis Bone scans Exclude underlying osteomyelitis Duplex Scanning Treatable venous, arterial disease CT Angiograms –Invasive Angiograms ( no longer done) –treatable arterial disease
Diagnosis
Provisional (early on) Final –constantly up date your diagnosis if slow progress (<0.1cm week) –seek second opinion –keep an open mind Almost all patients have either
Venous Ulcers Venous Anatomy and Function Deep system –Returns blood to heart Superficial system – (lie outside deep fascia and drain into deep system at SFJ,SPJ and through perforators) – Perforator system –Connects superficial and deep allows one way flow – Normal system
–Blood is pumped back to the heart by calf and foot pump. The valves prevent flow from deep to superficial.
Valvular Damage may occur because of thrombosis or varicose veins –causing reflux and or obstruction –Leads to high venous pressures in the superficial system to the capillary loop. –Swelling Induration Dermatitis Ulceration
Treatment
Compression Therapy •Bandage (high elastic / low elastic/ layered) •Stockings •IPC Treatment of Superficial Insufficiency •Sclerotherapy •EVLT •Surgery •Stockings •Reconstruction of Deep System?? •Drugs??
Diseases with arterial -arteriolar occlusion
Arteriosclerosis Obliterans
–The Major degenerative occlusive arterial disease of large and medium sized arteries of the extremities caused by atherosclerosis , medial arteriosclerosis or both –Men between 50 and 70 –Younger diabetic patients
Symptoms Signs Intermittent claudication diminished or absent pulses Rest pain delayed capillary filling Pain with elevation Buergher’s sign Ulceration AB Index <.8 Gangrene Biggest risk factor of overall mortally Ischaemic neuropathy AB Index <.5 <.8
Treatment Revascularisation Cessation of smoking, increase exercise, Trental, aspirin Wound care AVOID COMPRESSION, cautious debridement, moist dressings treat infection
Thromboangiitis Obliterans (Buerger’ Disease) –inflammatory segmental obliterative disease of medium and small arteries and veins distal to popliteal and brachial –Inflammatory vasculitis (infiltration of neutrophils and giant cells into to all layers of the vessel. Healing is associated with fibrous obliteration) –Males between 25 to 40 smokers –Clinical findings –Progressive gangrene of the extremities with auto-amputation Treatment –Cessation of Tobacco –Sympathectomy and amputation –Surgery can be confined to demarcated gangrene as there is good collateral circulation( in contrast to arteriosclerosis gangrene)
Raynaud’s disease or Raynaud’s Phenomena
Vasospastic condition elicited by exposure to cold results in pallor , cyanosis and rubor of hands & feet Primary Raynaud’s disease Secondary Raynaud’s phenomena (Auto immune diseases SLE , Scleroderma, Drug use) Young woman Colour change and numbness with cold Bilateral colour change blue to white to red 2 to 3 fingers affected and mainly finger tips Digital ulceration
–Treatment –underlying disease –Heat, avoid cold. Vibration –Vasodilators, Ca2+ Channel blockers –grafting
Arterial occlusion by embolism and thrombosis
–Embolism and thrombosis are the chief causes of arterial occlusion of the extremities. Large cholesterol plaques break off and occlude larger arteries, causing tissue infarction –Onset sudden –may occur –atrial fibrillation & myocardial infarction –after vascular surgery –cardiac massage –SBE spontaneously –Atheroembolism (cholesterol embolism syndrome) cholesterol crystals spontaneously break off from severely atherosclerotic plaques, occluding arterioles Treatment –Immediate anticoagulation /thrombolysis –Embolectomy
Arteriolar Obliterative Vasculopathy
–these vasculopathies have clinical features typical of non inflammatory vasospastic and obliterative phenomena of arteriolar structures rather than those of typical inflammatory necrotising vasculitides (Pyoderma Grangrenosum) –Vasculitis is an inflammation of blood vessels , they are classified on the basis of the size of the vessel affected Cutaneous Vasculitis
–Livedo reticularis and associated vasculitis –Atrophie Blanche –Hypertensive Ischaemic ulcers
Livedo reticularis and associated vasculitis
–Non specific clinical reaction that is associated with a number of conditions –fishnet like mottling of the skin and colour changes from reddish blue to deep blue mottling upon cold exposure –Idiopathic benign –Disease ? localised immune complex disease –Middle age woman •purpuric macules •haemorrhagic and blister –ulceration •painful and heal with depressed scars ,hypopigmented and stellate •associated with –SLE Anti phospholipid syndrome –RA Scleroderma –Dermatomyositis –necrotising vasculitis –Infections / Haematological disorders
Atrophie Blanche
– smooth ivory white plaque like lesions of the lower leg surrounded by hyper pigmented rims and telangectasia –Primary –often associated with other diseases –Chronic Venous Disease –Arteriosclerosis –Collagen diseases –Lymphoma –Leukaemia –polycythemia –Multiple and slow to heal
Hypertensive Ischaemic Ulcer
– Results from infarction of the skin caused by arteriolar occlusion in association with chronic hypertension. –Women 50 to 70 –lateral ankle and leg –painful red plaques to blisters then painful “punched out” ulcers –develop satellite lesions –Treatment –Analgesia , vasodilators platelet antagonists and anti hypertensive treatment –avoid compression therapy , excision and grafting is reasonable treatment –conservative care same as arteriosclerosis obliterans
Occlusive Vasculopathies Calciphylaxis –End stage Renal failure –progressive calcification of soft tissues and blood vessels –histology intimal calcification of medium size arteries and veins with thrombosis of vessel –large painful violet plaques that evolve into full thickness necrosis and gangrene Warfarin Induced skin necrosis –patients that have protein C deficiency –large painful violet plaques that evolve into full thickness necrosis and gangrene Intra-arterial injections –Anaesthetic , Chemotherapy , Sclerotherapy Antiphospholipid antibody syndrome –recurrent venous and arterial thrombosis –thrombocytopenia –foetal loss Cryoglobulinaemia and Cryofibrinogenaemia –immunoglobulins ,fibrin ,fibrinogens that reversibly precipitate in cold –Multiple myeloma , infections and auto immune diseases –livedo reticularis, Raynaud , small vessel vasculitis and painful leg ulcers
Diabetic Ulcers There is no such thing as a “Diabetic Ulcer" but diabetic patients with an ulcer which may be due to one or a combination of underlying pathologies • Angiopathy –large ,medium , small vessels •Neuropathy –sensory , motor , autonomic •Infection •Others Venous, Vasculitis
Angiopathy in Diabetic patients
–Peripheral vascular disease is very common –different pattern –Non diabetics occlusions or stenosis are most commonly found in the major proximal arteries iliac femoral , usually one leg and often single segment amendable to bypass angioplasty –Diabetics may occur as above but often more distal, smaller below the knee vessels are involved such as tibial or peroneal arteries and often more distal branches of these vessels. –Medial calcinosis (calcification of blood vessels can be very significant (I.e. non compressible)
Angiopathy in Diabetic patients •Risk factors for Macro vascular disease –Increasing Age –Duration of Diabetes –Smoking –Hypertension –Hypercholesterolemia •Diabetics can suffer adverse changes to small vessels –Retina –Renal –digits of lower limb
Neuropathy in Diabetic patients
Sensory Neuropathy –reduced or absent pain sensation can result in unnoticed trauma »Mechanical (tight shoes , sharp object) »Thermal (hot bath , water bottle too close to heater) »Chemical (Callus or Corn removers) Motor Neuropathy –foot deformity due to atrophy of the small muscles of the foot –clawing of toes and prominent metatarsal heads –change in gait and prolonged pressure leads to callus and ulceration –Under Head of first Metatarsal , enlarged bunions and bony prominence of the toes Autonomic Neuropathy –absence of sweating –dry skin »predisposes to fungal and bacterial infections
Neuropathy in Diabetic patients
•Unlike other ulcers Neuropathic ulcers develop initially deep within the tissues –Fluid collects infection follows ,abscess formation and then ulceration –the opening of the ulcer may be small hiding the true deep damage –Infection is common often down to tendons and bone
Pyoderma gangrenosum
•Ulcerative cutaneous condition of uncertain aetiology –50 % associated with chronic systemic diseases –Ulcerative colitis –Crohn’s disease –chronic active hepatitis –rheumatoid arthritis –monoclonal gammopathies –malignancies –50% Idiopathic –start as painful pustules –necrosis and ulceration –single or multiple ulcers –well-defined –raised , purple, serpiginous –undermined
Vasculitis and “other” Ulcers –Rheumatoid arthritis –SLE –Scleroderma –Polyarteritis Nodosum –Steroid ulcers –Traumatic ulcers –Lymphoedema –Self Induced –Oedema induced –Malignant –Infective –Sarcoma ,lymphoma –Blood Dyscrasia –Thalassaemia –Sickle cells disease –Leukaemia –Thrombocythaemia –Nutrition Conclusion
• Conditions that cross the domain of almost every major medical and surgical sub-speciality • Almost all patients have either • Venous Ulcers • Arterial ulcers • Diabetic ulcers • Other causes are uncommon but practitioners that care for patients with leg ulcers should be able to undertake investigative processes involved in diagnosis
Bibliography Fivenson, M. M. C. a. D. "Leg Ulcer Diagnosis and Management." Medical Dermatology 19(4). Negus, D. (1995). Leg Ulcers a Practical approach to management, Butterworth Heinemann. Moffatt, M. M. C. (1994). Leg Ulcers, Mosby.
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