Leg Ulcers

Surgical Essay

Discuss the management of a skin ulcer An ulcer is a breech in the epithelial surface. The aetiology of chronic leg ulceration is diverse but they can be diagnosed clinically. This is important since the different ulcers are managed in different ways. Venous ulcers are part of post phlebetic limb syndrome where there may be a history of DVT. The ulcer is associated with oedema, lipodermosclerosis and venous congestion with secondary calf perforations and varicose veins. The ulcer is usually over the medial malleolus but may be large, involving the whole of the gaiter region. Treatment includes bed rest and elevation of the foot in bed. Compressive therapy helps to heal and prevent recurrence of ulcers. Elastic compression achieves the best and most durable pressure. Multilayered compression, example the four layer bandage, uses many layers to even out the high and low pressure areas found under any bandage. Graduated compression keeps ankle pressure at 30-40mmHg and knee pressure 15-20 mmHg. Compression therapy must be avoided if there is arterial involvement. If foot pulses are absent, there may be an arterial element. This can be excluded by measurement of ankle to brachial pressure index (ABPI) which much be higher than 0.7. Surgical treatment involves skin grafts or ulcer bed clearance of slough or infection. Surgery is only reserved for superficial venous diseases. In mixed superior and deep venous disease, the role of surgery is controversial. Patients might also need arterial revasculisation. 1

Surgical Essay

Arterial ulcers are often multiple and occur distally over and between the toes or at pressure points like the heals. They may also be anywhere in the leg especially when associated with diabetic or venous elements. There is usually a history of arterial disease, especially peripheral vascular disease with claudication.Unlike in venous ulcers, where bacterial colonization is common; in arterial ulcers the presence of organisms suggests infection. If the leg is kept dry, infection is minimized. Nursing care for the ulcer is of utmost importance and opiates are used to provide analgesia, as arterial ulcers are very painful in contrast t venous ulcers. Arterial ulcers can also be treated endovascularly by angioplasty which can be combined with stent insertion. It is most successful for aortoiliac disease, common femoral and superficial femoral diseases. It is less successful for popliteal disease and very rarely used for distal disease. Surgical procedures include femorodistal bypass grafts for example to common peroneal or anterior tibial arteries. Amputation can be done as a last resort, which is usually below or above the knee in smoking related atherosclerosis. Diabetic ulcers commonly occur in conjunction with arterial diseases. They represent small and large vessel disease with an impaired ability to heal and a high susceptibility to infection. Ulcers occur at arterial distribution particularly at pressure points, and involve deep tissue infections and osteomyelitis.The associated diabetic neuropathy makes the feet susceptible to ulceration. Management includes good diabetic care, and ulcer care. Local or systemic infections should be treated by broad 2

Surgical Essay

spectrum antibiotics, debriding obviously dead tissue, draining collections of pus. If appropriate, re- vascularisation is considered: angioplasty, femerodistal bypass grafts and reconstruction to deal with vascular supply. Surgery aims to avoid major amputation but requires debridement of necrotic tissue, drainage of abscesses and excision of dead tissue, often involving bone. It is often possible to do limited distal amputations but may be progressive amputation if disease spreads. There are other rarer causes of ulceration: pressure, lymphatic, infective causes. Leg ulcer clinics have emphasised the value of a team approach. 17/01/09

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