A foot ulcer is a break in skin continuity on or around the feet that may be of arterial, venous or neuropathic aetiology.
Describing lesions
- Arterial ulcer
- βThere is a well-demarcated ulcer on the tip of the right great toe.β
- βIt has a diameter of 1cm and a punched-out appearance.β
- βThe ulcer has a necrotic base.β
- βThe surrounding skin is cool and pale, and the dorsalis pedis and posterior tibial pulses are very weak.β
- βThis lesion is characteristic of an arterial ulcer.β
- Venous ulcer
- βThere is a large superficial ulcer on the medial gaiter region of the right leg.β
- βThis has a diameter of approximately 14cm and has an irregular border.β
- βThe ulcer has an exudative, granulating base.β
- βThere is associated venous eczema and lipodermatosclerosis.β
- βThis lesion is characteristic of a venous ulcer.β
- Neuropathic ulcer
- βThere is a well-demarcated ulcer on the plantar aspect of the first metatarsophalangeal joint.β
- βIt has a diameter of 1cm and a punched-out appearance.β
- βThe ulcer has a granulating base.β
- βThe surrounding skin is hyperkeratotic and there is reduced sensation peripherally.β
- βThis lesion is characteristic of a neuropathic ulcer.β
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
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
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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
- Diabetic foot exam
- Lower limb arterial exam
- Find more here