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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.

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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 aorto-
iliac 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

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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