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Peripheral Ulcer Examination (Inspection: BEDS (Edge (Sloping: healing –…
Peripheral Ulcer Examination
Inspection: BEDS
3s
Site
Size
Shape
Base
Slough
Floor: bone, tendon, fascia
Granulation tissue
Edge
Sloping: healing – usually venous
Punched-out: ischaemic or neuropathic
Undermined: pressure necrosis or TB
Rolled: BCC
Everted: SCC
Discharge
Serous
Purulent
Sanguinous
Surroundings
Cellulitis
Excoriations
Sensate
LNs
Causes
Venous: 75%
Exam
Palpation
Painless
Warm surroundings
Sensate
Inspection
Site: medial malleolus
Size: variable, can be v. large
Base
Shallow
Pink granulation tissue
Edge: sloping edge
Discharge: seropurulent
Surroundings
Signs of chronic venous insufficiency: HAS LEGS
Varicose veins
Viva
Causes
Neuromuscular disease
Stroke
Muscle pump failure
Outflow obstructionOften post DVT
Deep vein reflux: e.g. post DVT
Varicose veins
Valvular disease
Ix
ABPI if possible
Duplex ultrasonography
Biopsy may be necessary: esp. if persistent ulcer
Look for malignant change: Marjolin’s ulcer
Mx
Refer to leg ulcer community clinic
General Measures
Optimise risk factors: nutrition, smoking
Analgesia
Bed rest + elevate leg
4 layer compression bandaging if ABPI >0.8
Construction
Non-adherent dressing + wool bandage
Crepe bandage
Blue line bandage: light compression
Cohesive compression bandage
Change bandages 1-2 x/wk
Once healed use grade 2 compression stockings for life
Other Options
Pentoxyfylline PO: ↑ microcirculatory blood flow
Desloughing c¯ larval therapy
Topical antiseptics: Manuka honey
Surgical: split-thickness skin grafts
Mixed arteriovenous: 15%
Arterial: 2%
Examination
Inspection
Site
Tips of and between toes
Base of 1st and 5th metatarsals
Heel
Size: mm-cm
Base
Deep: may be down to bone
May be slough but no granulation tissue
Edge: punched-out
Surroundings
Pale
Trophic changes
Palpation
Painful
Cold surroundings
Sensate
Reduced or absent distal pulses
Viva
Causes
Large Vessel
Atherosclerosis
Thombangiitis obliterans (Buerger’s Disease)
Small Vessel
DM
PAN
RA
Mx
Analgesia
Paracetamol + NSAIDs
Weak opioids: e.g. codeine
Strong opioids: e.g. morphine
Risk Factor Modification
Stop smoking
Control DM and HTN
Optimise lipids
Medical
Avoid drugs which may worsen symptoms: e.g. β-B
Low-dose aspirin
IV prostaglandins
Chemical lumbar sympathectomy
Chemical ablation of L1-L4 paravertebral ganglia
Inhibit sympathetic-mediated vasoconstriction
Relief of pain
Often unsuccessful in DM: neuropathy
Neuropathic
Examination
Inspection
Site: pressure areas
Tips of and between toes
Base of 1st and 5th metatarsals
Heel
Size: variable
Shape: corresponds to shape of pressure point
Base: may be deep w/ bone exposure
Edge: punched-out
Surroundings
Skin looks normal
Charcot’s joints
May be signs of PVD if co-existent arterial disease
Extras
Blood sugar testing marks on fingers
Insulin injection marks on the abdomen
Palpation
Normal temperature
Normal peripheral pulses
Absent sensation around ulcer
Absent ankle jerks
Completion
Full peripheral vascular exam
Cranial and peripheral neuro exam
Viva
Causes
Any cause of peripheral neuropathy
DM
Alcohol
B12
CRF
Drugs: e.g. isoniazid, vincristine
Every vasculitis
Pathophysiology
Sensory neuropathy: distal limb damage not felt by pt.
Motor neuropathy: wasting of intrinsic foot muscles and an altered foot shape
Claw toes + prominent metatarsal heads
Autonomic neuropathy: ↓ sweating → cracked, dry foot
Pressure
Vasculitis: e.g. PAN
Malignancy: SCC, Marjolin’s
Systemic: pyoderma gangrenosum
Palpation
Limb pulses
Sensation around the ulcer
Completion
Examine contralateral side
Distal neurovascular examination
ABPI: must be >0.8 for compression bandaging