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Leg Ulcer


Jason Mann

on 26 December 2012

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Transcript of Leg Ulcer

Following Injury No History of Trauma Leg Ulcer Neuropathic Pyoderma Gangrenosum History
Initial painful nodule
Ulcers elsewhere
PMH - IBD, Arthritides, Haematological disease Investigations
Biopsy and swabs to exclude others
?Cause (Inflammatory markers, RF, ANCA, FBC Examination
Ulcer - deep, well demarcated
Signs of systemic illness Peripheral Vascular Disease History
Intermittent claudication
PMH - Atherosclerosis, CVD, etc.
CV risk factors Investigations
ABPI (<0.9)
Arteriogram Examination
Punched out appearance
Signs of PVD - 6 P's
Skin changes - Thin, shiny, anhydrous, hair loss
Other signs of CVD
Site - peripheral Arterial clots History
Gradual onset - thrombous build-up
Acute - embolism from distal site
Haematological disease - Sickle cell, PV and TTP Investigations
ABPI, arteriogram
Investigate underlying disease Examination
Ulcer - 'punched-out'
Signs of artery occlusion - 6 P's
Signs of underlying disease Chronic Venous Insufficiency/Stasis Ulcer History
Preceded by skin changes
Relatively painless unless infected
Other indicators of venous insufficiency (varicose veins, ankle swelling, prev DVT)
Risk - obesity, immobility, Age Investigations
Rule out other aetiologies Examination
Medial aspect
Sloping wound edge
Skin changes
pitting oedema
venous eczema
lipodermosclerosis Vasculitic History
Varied onset
Preceded by other vasculitic skin changes
PMH - vasculitis
Systemic disease may be present Investigations
Biopsy can confirm
Screen for underlying cause e.g.
ANA/ENA for lupus/other AI
Screen for end-organ damage (routine bloods, urine dipstick) Examination
Punched out, deep
Atypical distribution
Other vasculitic manifestations BCC SCC Diabetic History
Diabetes ?control
Symptom review
Risk factors
Be aware of other contributing factors - PVD, infection, etc. Exam
Diabetic foot exam
Diabetic review - other systems Leprosy History
Other lesions
Eyesight disturbance Brainstorming Leg Ulcers An Idiots Guide: Vascular Neuropathic Venous (70%)
Arterial (2%)
Vasculitic Metabolic Haematological Neoplasia Infection Other Medication Exogenous Peripheral
Spina bifida
PoliomyelitisMS Diabetes,
Gout, Gaucher's
Disease, Porphyria,
Homocysteinaemia RBC, Leukocytes, Thrombocytes, Coagulation Pyoderma gangrenosum, Dermatitis
artefacta, bullous skin disorders Hydroxyurea
Extravasated cytostatic agents BCC
Cutaneous Lymphoma Heat,
cold, pressure,
radiation, artefacts,
noxious chemicals,
allergens Bacteria,
Protazoa Why not healing?

Concurrent disease
Inadequate treatment
Malignant change Pain Ischaemia Infection Primary Infection History
Risk factors
Systemic disease Investigations
Biopsy if suspicion
Blood tests
Tests for other manifestations Examination
Systemic signs
Other signs of TB/syphillis Secondary HAVE A HIGH INDEX OF SUSPICION
FOR ANY SUPER-INFECTION OF ANY ULCER Venous MM Neoplastic Tabes Dorsalis History
Sexual history, PMH
Hx of primary, secondary and tertiary syphillis

Signs of primary, secondary or tertiary syphillis Investigation
Dipstix, HbA1c, BM
Other ?cause e.g. abrasion, heat, cold, pressure, radiation, chemicals Neuropathic or other 'break in an eipthelial surface' Syphillis (tertiary), TB (cutaneous) Arterial Thrombo/Embolic Marjolin's ulcer Biopsy if any suspiscion N.B. may be painless Signs of infection

Pus or crust if dried (green/yellow)
Surrounding tissue - cellulitic
Swollen Streptococcus pyogenes, Staphlococcus aureus Dermatitis artefacta Manifestation of psychological condition
Injury deliberately induced by patient
Unusual presentation below the knee Swab to confirm Skin metastases Summary There are various causes
More than one factor may be contributing
People with diabetes may not feel pain from other causes of ulcer

In the history, get clues from:
How the ulcer developed
Any pre-existing medical problems
Symptoms of other diseases
On examination:
Characteristics of the ulcer
Signs of systemic disease References 1. http://www.sciencephoto.com/image/81423/large/C0017022-Leg_ulcers-SPL.jpg
2. http://4.bp.blogspot.com/-Fsv5C7l4HgQ/UI7I7iTOjFI/AAAAAAAAALc/-PsZf-fleBw/s1600/Diabetes_Foot_Ulcers-2.jpg
3. http://www.bidmc.org/CentersandDepartments/Departments/Surgery/VascularSurgery/DiseasesandConditions/Veins/~/media/Images/CentersandDepartments/Surgery/VascularandEndovascularSurgery/Medical%20Illustrations/Leg%20Veins.ashx
4. http://www.clinimed.co.uk/Portals/10/images/Figure%205%20VLU%20(holding).jpg
5. http://dermnetnz.org/dermatitis/img/grav-derm.jpg
6. http://www.vascularcarecentre.com/img/Leg%20ulcers/Arterial%20ulcer.jpg
7. http://www.aafp.org/afp/1999/0601/afp19990601p3153-f1.jpg
8. http://images.rheumatology.org/viewphoto.php?imageId=2897703&albumId=77030
9. http://www.sciencephoto.com/image/262641/large/M2600321-Gumma_in_syphilis-SPL.jpg
10. http://menstuff.org/logos/squamous.jpg
11. http://images.medicinenet.com/images/slideshow/skin_cancer_s19_basal_cell_carcinoma.jpg
12. http://upload.wikimedia.org/wikipedia/commons/thumb/6/6c/Melanoma.jpg/250px-Melanoma.jpg
13. http://upload.wikimedia.org/wikipedia/commons/thumb/c/c5/Marjolin_ulcer.JPG/250px-Marjolin_ulcer.JPG
14. http://www.dermis.net/bilder/CD051/550px/img0013.jpg THANK YOU Any Questions? Jessica Pearce
Jason Mann
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