Leg ulcers

Ulcers can be classified easily based on a few key characteristics:

• Compression ulcers
  • Based on pressure points - bone surfaces 
    • Elbows, shoulder blades, sacral area 
    • 
  • Pressure creates microvascular ischemia 
  • Common in patients who are bedridden or wheelchair-bound 
    • Paralyzed individuals 
  • Treatment= prevention 
    • Roll the patients every 2 hours 
    • Use soft materials and air mattresses 
    • Wound care 
      • Necrotic tissue debridement 
      • Antibiotics if cellulitis 
      • Keep it clean
• Diabetic ulcers
  • 
  • Caused by microvascular changes and neuropathy 
  • A mix of compression and arterial ulcers 
  • Distal arteries and nerves affected first 
  • Heels, bases of the feet common sites 
  • Clinical diagnosis 
    • Monofilament test for neuropathy
  • Treatment/Prevention
    • Control blood glucose 
    • Elevate legs
    • Amputation last resort  
    • Inspect the feet to catch early ulcers 
    • Get fitting shoes to avoid compression 
• Arterial insufficiency ulcers - problem with getting blood in 
  • 
  • Peripheral vascular disease = macrovascular 
  • Symptoms 
    • Shiny/Scaly skin 
    • Hairless 
    • Absent pulses
    • Distal ulcers - the tip of toes 
  • Diagnosis 
    • Ankle-brachial index 
    • U/S arterial duplex 
    • Angiogram 
  • Treatment 
    • Wound care 
    • Stent and bypasses 
      • Stent small lesions above the knee
      • Bypass large lesions or lesions of the popliteal artery 
• Venous insufficiency ulcers - problems with getting blood out 
  • 
  • Venous blood stasis 
  • Edema 
  • Stasis dermatitis 
    • Deposition of hemosiderin = hyperpigmentation
    • Woody skin 
  • Medial malleolus common location due to a rich venous plexus in that region  
  • Treatment 
    • Compression stockings
      • Contraindicated if the ankle-brachial index is under 0.7 (arterial insufficiency) 
    • Elevation of the legs 
    • Diuresis 
• Marjolin ulcers
  • 
  • Squamous cell carcinoma 
  • Ulcer with a sinus tract 
  • Breaks and heals over and over
  • Margins are heaped up 
  • Diagnosis 
    • Biopsy 
  • Treatment 
    • Wide margin resection

Staging of ulcers

• Stage 1 = non-blanching erythema 
  • 
  • Painful
  • On the skin 
  • Only affects the epidermis 
• Stage 2 
  • Epidermis and dermis both affected 
  • Fascia not affected 
  • 
• Stage 3
  • Can see the fascia, not bone or muscle 
  • 
• Stage 4
  • 
  • Muscle and bone are exposed 
  • If the bone can be seen = most likely osteomyelitis