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Arterial ulcer

Definition

  • Arterial ulcers, also known as ischemic ulcers, are wounds that occur due to inadequate blood flow, typically in the lower extremities. They result from arterial insufficiency, where there’s a reduction in blood flow to the extremities, leading to tissue ischemia and necrosis.

Pathophysiology

Etiology

  • Commonly caused by atherosclerosis, leading to decreased blood flow.
  • Other causes include thromboangiitis obliterans, diabetes mellitus, and traumatic injuries to arteries.

Mechanism

  • Reduced arterial flow leads to tissue hypoxia and necrosis.
  • The lack of sufficient blood flow impairs wound healing processes.

Clinical Features

Appearance

  • Located on areas of the feet and legs where there’s the least amount of subcutaneous tissue, like toes, lateral malleolus, or shin.
  • Typically small, round, and well-defined with a “punched out” appearance.
  • The base of the ulcer is usually pale, with minimal to no granulation tissue, and may be covered with necrotic tissue.

Symptoms

  • Pain is a significant feature, often severe and exacerbated by leg elevation.
  • Patients may report intermittent claudication or rest pain.

Associated Findings

  • Signs of peripheral arterial disease like diminished or absent pulses, pallor on elevation of the limb, and dependent rubor.
  • Trophic changes such as hair loss, thin shiny skin, and atrophy of subcutaneous tissue.

Diagnosis

Clinical Assessment

  • Thorough history focusing on risk factors like smoking, diabetes, and hyperlipidemia.
  • Physical examination for arterial insufficiency signs.

Investigations

  • Ankle-brachial index (ABI) measurement is essential for assessing arterial flow.
  • Doppler ultrasound and angiography can be used for detailed vascular assessment.

Management

General Principles

  • Primary aim is to improve arterial blood flow.
  • Control of risk factors like smoking cessation, glycemic control in diabetics, and management of hyperlipidemia.

Wound Care

  • Local wound care includes debridement of necrotic tissue and appropriate dressing.
  • Pain management is crucial due to the painful nature of these ulcers.

Surgical Intervention

  • Revascularization procedures, such as angioplasty or bypass grafting, may be necessary in severe cases.

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