Foot ulcers

A foot ulcer is a break in skin continuity on or around the feet that may be of arterial, venous or neuropathic aetiology.

Suggested approach to foot ulcer osce station

Describing lesions

• Arterial ulcer
  • ‘There is a well-demarcated ulcer on the tip of the right great toe.’
  • ‘It has a diameter of 1cm and a punched-out appearance.’
  • ‘The ulcer has a necrotic base.’
  • ‘The surrounding skin is cool and pale, and the dorsalis pedis and posterior tibial pulses are very weak.’
  • ‘This lesion is characteristic of an arterial ulcer.’
• Venous ulcer
  • ‘There is a large superficial ulcer on the medial gaiter region of the right leg.’
  • ‘This has a diameter of approximately 14cm and has an irregular border.’
  • ‘The ulcer has an exudative, granulating base.’
  • ‘There is associated venous eczema and lipodermatosclerosis.’
  • ‘This lesion is characteristic of a venous ulcer.’
• Neuropathic ulcer
  • ‘There is a well-demarcated ulcer on the plantar aspect of the first metatarsophalangeal joint.’
  • ‘It has a diameter of 1cm and a punched-out appearance.’
  • ‘The ulcer has a granulating base.’
  • ‘The surrounding skin is hyperkeratotic and there is reduced sensation peripherally.’
  • ‘This lesion is characteristic of a neuropathic ulcer.’

Venous ulceration

Neuropathic ulcer

Necrotic ulceration

Trophic changes with bilateral callous formation and early ulceration

Other aspects of examination

• Surrounding skin (including temperature)
• Peripheral pulses and capillary refill
• Peripheral sensation 

If you are required to ask the patient questions

• Associated pain and when this is worse
• Loss of sensation
• History of diabetes, vascular disease, varicose veins, DVT

Types of foot ulcer

Possible investigation to determine cause

• Fasting glucose: to exclude diabetes
• Ankle brachial pressure index: <0.9 = peripheral vascular disease
• Duplex ultrasound: to look for peripheral vascular disease or venous incompetence
• X-ray: to exclude osteomyelitis
• Swabs for MC&S: if signs of infection

Time for some viva questions

What are the 6 P’s of an acute ischaemic limb?

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In what circumstance may ABPI be falsely elevated?

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How would you manage venous ulceration?

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Try some related OSCE stations

1. Diabetic foot exam
2. Lower limb arterial exam
3. Find more here