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Venous Leg Ulcers - Lower Extremity Venous Ulceration - Coggle Diagram
Venous Leg Ulcers - Lower Extremity Venous Ulceration
Definition
Interruption of an epithelial surface
Disruption of the skin with erosion of the underlying subcutaenous tissue
DDX
Arterial 10%
venous 70%
PRessure
Neuropathic 20%
Marginal (cancerous)
Mixed
Venous arterial
Arterial diabetic
Rare < 5%
Lymphoedema
skin cancer
Physical trauma / pressure
Vasculitis
Autoimmune - sclerodermA
Metabolic - Calciphylaxis
Ulcerating skin disease - pyoderma gangrenosum
Venous Ulcers
Clinical Features
Gaiter area
Painless
Weeping
Oedema
Brown skin
RF
Hx VV's
Hx DVT
Hx IVDU
Mx
Compression bandaging
Management
ABCD
Assessment
Wound
Site
Size
Base
Exudate
Surrounding skin
PULSES
PT
Age
Mental state
Self sufficiency
Nutrition
Co-morbidities
Best local dressing
Debridement ( Intrasite)
Paste (Ichthopaste / Viscopaste)
Absorptive ( Aquacel, Sorbien)
Antibacterial ( Iodine, silver...
Compression if local circulation intact
Compression Bandages - Multilayer
Short stretch
Long stretch
Graduated Compression Stockings
Class I ( 15-20 mmHg)
Class II (20-30mmHg)
D - Underlying disease management
ESHCAR study was used - now EVRA study used
ESCHAR
Surgical correction reduced 12month ulcer recurrence
Compression Vs superficial venous surgery and compression
EVRA study
Early intervention (Endothermal ablation and compression) vs Usual care (endothermal ablation after wound healed)
Early intervention - shorter time to healing
Practical problems in clinical care with access
Endothermal Ablation EVLT
Complications
Recurrence
35% at 2y, 65% at 11yr
Due to
Neovascularisation
Deep venous insufficiency
Incompetent perforators
Surgical failure
DVT ~ 1%
Numbness / Neuropathy
Saphenous / sural nerve runs with saphenous vein
20% transient
1% long term
Pain
Infx
Bleeding
US Guided Foam Sclerotherapy
Tessari method
Foam - air and alcohol
Chemical phelitis
Diabeteic
Clinical Features
Pressure points ( metatarsal heads )
Painless ( sensory neuropathy)
Deep
CAllus
Architectural deformities
Neuropathic / pressure ulcers
RF
Hx DM
Arterial
Critical limb ischamia
Gangrene
Pain
Uclers
Clinical Features
Distal
Pressure points
Painful
No palpable pedal pulses - critical limb ischaemia
+/- gangrene
RF
CVD risk factors
Smoking
High cholesterol
MX
Revascularisation
Investigations
ABI - Ankle brachial index
Doppler used to eval lower limb circulation
Used when no pedal pulse
Procedure
blood pressure cuff
Brachial pulse measure first
Normal range
0.9 - 1.4 ratio
Greater than 1.4 - Calcification / vessel hardening
Less than 0.9 - Arterial disease
Less than 0.4 - Severe arterial disease / critical limb ischaemia
venous Disease
Superficial Venous duplex US
Physical Exam
Vital signs / BMI
Inspection
Location
Inside of ankle - venous
Size
Base
Granulating - healthy wound base pink and not fibrotic/ infected / more likley to be prone to epithelialisation - likely to heal
Primary dresseding based on base of ulcer
Exudate
Diabetic and arterial are not ass with exudate
Venous ulcers ass exudate
Surrounding skin
Reticular veins
Varicose veins
Oedema
Eczema , lipodermatosclerosis (inverted champagne bottle), atrophie blanche
Healed venous ulcer
Active venous ulcer
C0-C6
Ask pt to stnad and inspect for varicose veins - which trunk is incompetent
Pedal pulses
Chronic Venous Hypertension
20% pt with Chronic venous htn have secondary lymphoedema
Signs
Positive Stemmer sign - inability to pinch skin at base of second toe - pathomneumonic for lymphoedema
Sausage shaped toes
Fissuring
Buffalo hump - dorsal foot swelling
Ski-slope nails
Peau d'orange
Cobblestoning
Elepahantiasis