Ulcers
last authored:
last reviewed:
Introduction
Almost a third of adults have venous disease.
Venous stasis ulcers affect 1% of the population, with 50% of people have an ulcer history of 10 or more years.
Diabetic neuropathic ulcers usually develop over areas of pressure (mal performans)
The Case of...
a simple case introducing clincial presentation and calling for a differential diagnosis to get students thinking.
Causes and Risk Factors
Venous disease is the most common cause of venous ulcers.
Risk factors include:
- age
- obesity
- previous history of leg trauma or phlebitis
- multiple pregnancies
- prolonged sitting or standing
Pathophysiology
The superficial venous system is lower pressure than that of deeper veins, to which they are connected by communicating veins.
Problems with venous valves, usually due to damage by thrombosis or infection, can lead to a rise in venous hypertension. Tissue edema can result in relative anoxia.
This may be due to increased deposition of fibrin around vessels as a pericapillary cuff, leading to decreased nutrient diffusion.
Signs and Symptoms
- history
- physical exam
History
Features of poor arterial circulation incude:
- dry, scaly skin
- soft tissue atrophy
- absence of hair
- tendency of heel fissures
- decreased or absent pulses
- toes can be red when used but pale when elevated
5 P's:
- pain - intermittent claudication and supine nocturnal pain, relieved by foot dangling
- pallor
- paresthesia
- pulselessness
- paralysis
arterial ulcers tend to be:
- punched out
- painful
- little bleeding on manipulation
Physical Exam
Venous ulcers
- Pitting edema
- hyperpigmentation or hypopigmentation
- tissue sclerosis
- ulceration, due to relative anoxia
ulcers tend to be irregularly shaped, with well defined borders. They are typically near the malleolus. Venous stasis ulcers never ulcerate to the tendon.
Investigations
- lab investigations
- diagnostic imaging
Lab Investigations
Diagnostic Imaging
Doppler studies can be done to determine ABI and flow studies.
ABI is not always useful due to falsely elevated readings due to arterial calcification.
Toe pressures may be taken, but require specialized vascular laboratories.
Cultures are not normally helpful as plymicrobial growth is common.
Differential Diagnosis
Treatments
Arterial ulcers
healing will not take place in an ischemic ulcer unless adequate blood supply is achieved
do not debride or use compression therapy.
minimize potential for infection by using povodone-iodine
vasodilators not useful, as ischemia is itself is a potent vasodilator, and systemic vasodilation could shunt blood to areas of lower perfusion.
Anti-platelet therapy - clopidogrel or ASA may be used.
Venous ulcers
Treat the ulcer with TIM:
- tissue debridement
- infection and inflammation control
- moisture balance
treat the leg with compression therapy is ABI is sufficiently high.
Neuropathic ulcers
Debridement is required, followed by antibiotic therapy. Off-loading is required to remove pressure from affected areas.
Vascular supply is generally adequate for healing
Consequences and Course
Resources and References
Topic Development
authors:
reviewers:
 |