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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.’

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?

In what circumstance may ABPI be falsely elevated?

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How would you manage venous ulceration?

Try some related OSCE stations

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

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