You are reviewing 39 yrs male patient with left leg ulcer in your clinic, he came to the clinic on a wheelchair accompanied with a family member, he stats he had car accident 5 yrs ago that caused spinal injury and residual paraplegia. The ulcer is 1 yr old and he mentioned a background of varicose veins in the same leg. No history of DVT.
Q1: What is your provisional diagnosis? Can you please justify your answer?
Q2: Is there any other provisional diagnosis (apart from your answer in Q1) relevant to this case?
Q3: What signs in the clinical examination that would support your diagnosis and rule out other pathologies?
Q4: What are the management options, what are the risks associated with them, which one you will offer to the patient and how will you counsel him for it?
A1 mostly venous ulcer due to history of vv and dependency lead to venous stasis and venous leg ulceration
A2 may be neuropathic ulcer due to paraplegia
may be ischemic ulcer
may be traumatic ulcer
A3 presence of varicosities
edema – lipodermatosclerosis – venous ulcer in gaitter area
and characteristics of ulcer with floor of granulation tissue -presence of inverted champaine bottle leg
intact pulsation
A4 complete examination and duplex assessment for superfical and deep system and arterial system
conservative treatment is the mainstay in treating venous ulcer
like compression stocking
elevation of leg
physiotherapy
surgical option like stripping of varicosities
injection sclerotherapy
ulcer care and dressing
i will offer compression therapy to the patient
and counsel the patient for importance to strict to the treatment and possibility of recurrence
Q1 : Venous leg ulcers.
Because patient had history of Varicose Veins which indicates Venous insufficiency.
Q2: pressure ulcers (sedimentary life style due to spinal injury).
Q3:anatomical site of Ulcers on the course of GSV or Perforators. Chronic skin changes in case of Chronic venous insufficiency.
Intact Distal pulse to Role out Ischemic ulcers in CLI.
Q4: treatment options mainly rely on Compression therapy and Venotonics (risk of Ischemia if Patient have Chronic ischemia)
Surgical Intervention in form of treatment of perforators or GSV.
Or sclerotherapy.(Which may have risk if PE.)
I would offer the patient the fitst line of treatment which is conservative ttt in form of Compression therapy and Venotonics.
I would explain to him the need for adhering to conservative ttt to avoid invasive intervention, and monitor improvement.
Especially that the Venous ulcers would be considered a chronic lesion that needs care and follow up
Q1: venous ulcer, Hx of VV, and dependency on wheelchair will predispose to Venous ulcer
Q2 : prssure ulcer due to contact with the Bony prominence
Q3 : Edematous limb, pgimentation,eczema,lipodematosclerosiz,intact peda pulse,Site of the ulcer
If in gaiter area it is mostly venous ulcer, high ABPI
Q4: Best managment willbe the the Compressint as the patient is bedridden so he will nog benefit from the intervention, and on contrary there may be risk of DVT, may be the Ulcer is due yo perforators So we Can consider injection sclerotherapy of the perforator
If there is no signs of ischemia we ca n consider skin grating
1 mostly due to venous problem
Due to location in leg , H/o of VV and paraplegic with calf ms atrophy
2 ischemic , neuropathic , traumatic
3 intact pulsation , pigmention , dilated veins and lipodematosclerosis
4 many options according to venous duplex results
In case of GSV refluxing
EVLA
RF
Venaseal
Injection sclerotherapy.
Stripping
If Competent GSV with incompetent perforator l do sclerotherapy or tipple ligation
But I will start conservative ESC
Limb elevation, venotonics and avoid antiseptic material mostly it will heal
start GCS with relevant class
venotonics
leg elevation
assessment of venous system and its competency
exclude that the patient doesn’t have any arterial insufficiency
A1 my provisional diagnosis is venous ulcer because the patient suffer from varicose vein and paraplegia which cause loss of the tone of calf muscle and venous stasis in the lower limb
A2 pressure ulcer due to prolonded immobility and bed ridden
A3 swollen limb _ congested veins in the lower limb _ prescence of the ulcer in gutter area _ skin changes around ulcer like black discoloration of the skin around the ulcer
A4 management options
thermal ablation of GSV with laser or radiofrequency
thermal ablation of pathological perforators related to ulcer
i will offer the patient conservative management
A1: provisional diagnosis of a venous ulcer due to decreased muscle pump action on venous return and because of previous varicose veins
A2: neuropathic ulcer, ischemic ulcer and pressure ulcer
A3: location of the ulcer, edema and skin changes
A4: I’d advise against surgical intervention as patient is already immobile and without use of his leg, and would rather provide conservative treatment like elastic compression stockings and basic wound dressing
Q1) venous ulcer
Q2) Neuropathic ulcer, ischemic , pressure ulcer
Q3) General examination : I will check for presence of fever ( to rule out septicemia due to ulcer infection )
local examination : inspection (site of the ulcer, presence of discharge or hyperemia suggestive of infection , shape of the ulcer to rule out malignant transformation)
pulse examination to rule out ischemic or mixed ulcer
Q4)
investigation will include venous duplex to check for reflux or obstruction
management option : regarding ulcer will include daily dressing , if there is signs of infection ; I will start broad spectrum antibiotics and do culture and sensitiviy , foot X-ray to exclude any ostemyelitic bones
if the cause is venous my first option is to try conservative management with elastic stocking and multilayer compression if there is no arterial problem
second option I will consider management of superficial system whether in the form of sub ulcer venous plexus injection , EVLA , foam sclerotherapy
Q1 – my provisional diagnosis is venous ulcer
Q2-Arterial ulcer
Neuropathic ulcer
Pressure ulcer
Q3-signs of CVI in the same leg
HX of VV
site if the ulcer
Q4-In my opinion in this case the best management is : conservative
Daily dressing with elastic stockings
& venotonics with some instructions to the patient
No surgical intervention is required in this case to not exacerbate the problem & to avoid risk of DVT .
Q1 my diagnosis is venous ulcer
Q2 pressure ulcer’ neuropathic ulcer ‘ arterial ulcer, mixed pathology ulcer should be considered
Q3 location of the ulcer is very important, Venous Ulcer the location is typically in the medial gaiter region ,Pressure Ulcer is over bony prominences ,Arterial Ulcer: usually peripheral as tips of toes with absent pulses,Neuropathic Ulcer on plantar aspect and pressure points with Lack of sensation
Q4
for this patient i will recommend only compression therapy with standard wound management
This comment is for all candidates:
Always when you are thinking about an intervention, ask yourself ( what is the goal you want to achieve? and what are the risks I will expose the patient to?
Venous leg ulcer in general can be disabling to people who are active and working, limiting their life style and causing much cost for dressing, therefore investigating the superficial system to ablate the refluxing veins aiming to accelerate the ulcer healing and prevent future recurrent will improve the life style of this person, reduce the number of day this person is absent from work and reduce the cost.
The patient in this scenario is already paraplegic, not active, even if the ulcer heals quicker his lifestyle will not change, on the other side you are exposing him to higher risk of DVT and PE which can be fatal. Also, even if you ablate the refluxing superficial veins, you will not be able to fix the functional venous insufficiency related to the immobility and the non-active calf muscles which may lead to recurrence of the ulcer despite your intervention.
q1- venous ulcer because
of presence of varicose veins and ulcer happened after paralysis because of failure of muscle pump for venous return
q2- — pressure ulcer because of loss of sensation
— leg ulcer after lower limb cellulitis complicated by lipodermatosclerosis
q3 – site of ulcer on the medial aspect of lower leg
q4 – investigation : venous duplex – to rule out ( reflux )
ct venography to rule out maythurner syndrome ( obstructive )
risk of CT ( radiation and dye exposure )
management :
i would begin with compression therapy
if failed i will go for CIV stenting but with high risk of thrombosis because he is not active patient
so i will offer him the compression elastic bandages therapy
Thank you Dr Peter for the answer, I mentioned in previous comments the superfical venous intervention would be considered high risk, so deep venous intervention will carry much higher risk. May-thurner syndrome has its own diagnostic criteria and indication for intervention which are outside the scope of this module. But an important factor when offering deep venous intervention is the patient selection. What are we trying to achieve in this patient.
Q1 my provisional diagnosis is venous ulcer as the patient has hx of vv and suffering immobility which increases venous stasis
Q2 many other causes such as pressure ulcer (over bony prominence), neuropathic ulcer especially with hx of neurological deficit, arterial ulcer, or even mixed pathology ulcer
Q3 generally location of the ulcer is very important, as in Venous Ulcer the location is typically in the medial gaiter region.
oedema and other skin changes of CVI
and to Rule Out other causes :
back to the location Pressure Ulcer is over bony prominences (e.g., sacrum or heels).
Arterial Ulcer: usually peripheral as tips of toes accompanied by diminished or absent pulses..
Neuropathic Ulcer:
usually on plantar aspect and pressure points, with Lack of sensation on sensory examination.
Q4
for this patient i will recommend only compression therapy + standard wound care provided thar there is intact distal pulse
my counselling will discuss the chronic nature of the disease and how to manage the wound properly
Well done Dr Muhammad.
Q1 venous ulcer provided pt has varicose veins in same limb , setting for long time (paraplegic in wheelchair) , loss of calf pump effect ( no walking)
Q2 neuropathic ulcer pt has paraplegia loss of sensation, pressure protective ( pripoceptive mechanisms
Q3 site of ulcer(gater region) ,, skin changes ( lipodermatosclerosis – atrophic Blanche) , edema
Q4 duplex refluxing gsv and or incompetent sfj , spj , perforators
Mangment options 1-conservative ( graded elastic stocking class 2 ) 2- operation (open surgery disconnection sfj +_ stripping , ) evla , radio frequency, venosel
Thank you for your answer. The conservative treatment (the compression) can be with stocking or with multilayer compression bandage.
In Q4 you mentioned 2 management options, which one you will offer the patient, 1, 2 or both?
Conservative Management multilayer compress bandage till Ulcer heal then elastic stocking
A1 the provisional diagnosis is venous ulcer
as pt has Hx of Varicose veins and exacerbated venous congestion due to paraplegia and loss of calf muscle function to facilitate venous return also being paraplegic would increase his lower limb dependency by effect of gravity
A2 could be pressure ulcer due to contact with bony prominences and pressure necrosis
A3 presence of venous limb – lipodermatosclerosis and ulcer in the ulcer bearing areas ex . Above medial Malleolus symptoms of venous dx as improvement of complaint by leg elevation – a science of pressure sores on areas of contact with bony prominences- intact pedal pulse with ABPI above 0.7
A4 several management options are available first is surgery. Patient can undergo stripping or thermal ablation of incompetent veins another option is conservative management to elastic stocking and leg elevation. I would choose the first option of operation varicose veins for being for me associated with desperate ability and less operative time, and also the presence of venous ulcer would improve with ablating incompetent perforators if present. The risk of surgery include hematoma formation with stripping and DVT with thermal ablation
I would council the pt by giving all ttt options and would give him a proposed plan for endovascular laser ablation given its less operative time and less morbidity with increasing a chance of healing of the ulcer and council about lifestyle, modifications, including leg elevation, and it does take a stocking with the use of medications as tetracycline and daflon is dressing over the answer with salon and antibiotic cream until its healing
Well done with answers 1-3.
I disagree with 4.
DVT is risk for any venous intervention not just the thermal.
Surgery will carry even higher risk e.g wound infection, hematoma, anaesthesia.
In this patient status, venous intervention is not advised.
A1: my diagnosis would be chronic venous insufficiency as result of his varicose veins and I could attribute that to patients medical history of varicose veins in addition to his paraplegia which augmented the gravity of his condition by the continuous leg depenecy of the wheel chair and muscle atrophy .
A2: other causes of the ulcer may be due to arterial lesion ,traumatic including thermal injury, infective causes,pressure atrophy,vasculitis lesions and mixed arterial and venous etiology
A3:to support my diagnosis I would assesss my patient;s varicosites and its extent in addition to examining the ulcer regarding the the site,size,margins and base and surround area to identy the nature and exclude presence of infection and malignancy and ischemia and stratify my finding according to CEAP classification
in addition examination of the arterial supply to the lower lims by examining pulse and doppler examination and assess the neurolocal deficit level including the sensation , motor power and proprioception.
A4: my intia; management will be directed to assess his general condition in the form of lab investigation to exclude anemia, infection and liver and kidney disease then regarding the ulcer i would go for duplex examination to identify the reflux in superficial system and refluxing perforators in addition to ulcer management and compression therapy
after duplex assessment I would prefer treating the varicose veins by venous ablation either laser or RFA or NTN recniques according to availability of the resources and perforator manament either by injection sclerotherby or by ablation
ulcer management by peri- ulcer injection and compression thepay
if there are any infection ulcer debridment should be done and inspection of margolin should direct me to biopsy after all that Iwould continue compression therapy to help the ulcer healing
risks for ablation include thermal injury and burning of the skin in addition to heat induced thrombosis “EHIT”
injection would inglude migration of sclerosant material to the deep system inducing DVT and skin necrosis
councling the patient must in the form of step by step approach first i need to examine the condition he is having and imaging results followed by illustrating even in drawing or images how will i use these treatment options and and its complication and advice him that are treatments are suitable and minimally invasive and explain my reasons of my interventions to avoid disease progression and reassure him and respect his opinions and concerns
Thank you Dr Khater for the informative answer, I agree with you regarding the diagnosis ( likely venous ulcer due to both the varicose veins and the immobility) but I disagree with the management, since the patient is not mobilizing thr risk of DVT with venous intervention is very high, also as per the available evidence in venous disease, the benifit from intervention is accelerate the healing and prevent recurrent, without the intervention the ulcer will also heal with compression.
1- Chronic venous ulcer due to history of varicose veins, recumbency for long duration with long standing ulcer for 1 year duration, increased venous pressure, weak calf muscle pump.
2- Neuropathic ulcer
Ischemic ulcer
Pressure ulcer
Marjolin ulcer
Mixed ulcer….arterial and venous
Vasculitic ulcer
3- Presence of skin pigmentation, lipodermatosclerosis, edema, ulcer at gaiter area, telangectasia, visible dilated veins, support the diagnosis of venous ulcer.
Intact distal pulsations and normal ABPI exclude presence of ischemia.
4- Starting by investigations:
-Laboratory:
CBC to exclude presence of sepsis
HgbA1C to exclude DM
ESR and CRP to exclude vasculitis
-Biopsy from the ulcer to exclude marjolin ulcer
-Woundswab fro the ulcer for culture and sensitivity tests
-Plain X ray to rule out osteomyelitis
-Non invasive:
ABPI measurement to exclude arterial ischemia
Arterial duplex U/S to rule of arterial ischemia
Venous duplex U/S to exclude DVT, reflux of SFJ or SPJ, to exclude STPs
Treatment in from of:
Limb elevation
Antibiotics according to culture test
Prophylactic anticoagulant in case to recumbency
Compression therapy
foam sclerotherapy around the venous ulcer with risk of skin pigmention or skin necrosis
Laser ablation of varicose veins with risk of skin burn
Phlebectomies if needed
Well done Dr Ahmed, good answer but again I dis agree with the intervention due the causes I mentioned in the previous comment.
Q1 mostly venous ulcer due to VV hx
Q2 may be pressure ulcer due to pt hx of spinal injury
Q3 site of ulcer , character of pain in ulcer , and imaging that support CVI
Q4 if I confirm my diagnosis i will recommend compression therapy and vasotonice drugs
Thank you Dr Osman, well done, it is focused and concised answer, the provisional diagnosis can include other causes but the mentioned the 2 that are very relevant, definately I will consider venous vs neuropathic vs arterial vs mixed.
Well done offering compression only.
I will always exclude co-existing arterial cause by feeling the pulse or measuring the ABPI before proceeding with the compression.
1 Mostly venous ulcer
Due to h/o of varicose viens in the same leg which may indicates superficial venous reflux
2 May be pressure ulcer d.t spinal cord injury and the recumbency of the pt
3 by inspection : oedema , hyperpigmentation of the lower leg , visible varicosities and the ulcer characteristics especially the site if it’s in the gaitre area
by paplation: dilated superficial viens, intact distal pulsation
4 treatment options
After doing the investigation as US venous duplex
Superficial reflux must be treated by thermal ablation with/without UGIS of perforators around ulcer
+ Compression therapy , leg elevation, medical ttt and ulcer wound care
Risks is according to medical history and pt fitness plus the side effects of the procedure
Counseling him that you have a venous ulcer which is chronic venous disease due to superficial venous reflux which needs treatment (as described above) which is interventional then conservative ttt
But interventional may carry risks(as mentioned )
Good focused and concise answer, well done.
only disagree with the intervention.
Thanks dr mohmmed , So if the pt is not paraplegic , will you reccommend the intervention or not?
I will definitely offer ablation of the superficial veins + the compression if the patient is fully mobile. This Class 1 recommendation in ESVS guidelines and NICE guidelines.
Q1 my provisional diagnosis is Venous ulcer . This is suggested by history of varicose veins at the same leg long recumbency decrease venous return causing venous stasis .the young age of the patient is more with venous .long standing non healing ulcer .
Q2.. neuropathic ulcer due to spinal injury and paraplegia
Bed sore
Arterial ischemic ulcer
Mixed pathology in form of mixed venous and neuropathic pathology
Mixed pathology due to possible arterial and venous pathology
Marjolin ulcer …. squamous cell carcinoma
Diabetic ulcer
Vasculitic ulcer
Inflammatory ulcer
Q3 ulcer in gaiter area will be venous
If surrounded by telangectasia and varicos veins .if the patient have intact pulse will exclude arterial ulcer . If the patient have loss of hair around ulcer and at heel or foot and have trophic changes in form of nail changes may be neuropathic ulcer. if the patient has first discovered diabetes .may be Diabetic leg or foot ulcer .if the patient has symptoms of vasculitis and raised esr and crp may be vasculitic ulcer .we will do detailed arterial and venous and neurological examination .we will do detailed ulcer examination of ulcer edge ,margin,floor, base to differentiate types of ulcer
If the patient has skin changes and lipodermatosclerosis will suggest venous ulcer
Q4mangement in form of diagnosis and treatment .diagnosis depends on clinical examination , laboratory investigations , and radiological investigations and minimally invasive procedures. Laboratory in form of cbc to show if wbcs are high it may suggest infection at ulcer and to show if platelets are normal or low or high .also I will do inr if I prepare the patient for any intervention regarding ultrasound guided sclerothrapy of vein surrounding ulcer .also I will do crp or esr to exclude vasculitic ulcer .I will also do RBS and Hba1c to exclude diabetes . I will also measure ankle brachial index and toe pressure if there no pulse . I will also do arterial and venous duplex to exclude any type of ischemia and to ensure the state of arterial wall and and venous duplex to exclude deep venous thrombosis or chronic venous insufficiency and to ensure patency of if there is thrombosis of superficial and deep veins or together and to ensure competence of valves . Also I may need to do x ray to exclude osteomyelitis . I will need to take a biopsy from it to exclude marjolin ulcer .I will need to do blood culture .may need to do nerve conduction study .as regard treatment for venous ulcer in form of compression therapy and may need ultrasound guided sclrotherapy of feeding vein and stabilization of neurological condition
Thank you for your informative answer.
I would manage the venous ulcer with compression alone in this patient.
1-Scenario is going with chronic venous ulcer due to superficial venous reflux given the history of VV and loss of calf pump function due to paraplegic also relatively long history for 1 yr
2-It may be a pressure ulcer from the wheelchair especially if he is used to set for prolonged periods
May be arterial ulcer if he is an active smoker and has Burger’s disease
May be pyoderma gangerenousum with irritable bowel disease
May be on top of chronic osteomyeltic bone in fracture site due to the accident
3- starting with history of insidious onset and chronic course and associated complaints of pain, oedema and heaviness increasing by leg dependency and improved by elevation
Site of ulcer over gaitre area
Inspection should show skin changes of pigment. eczema ,thickening
Ulcer description of rolled out edges equal margins and surrounding venules
Palpable distal pulse and normal ABI rule out arterial ulcers
Good hygiene and nutritional status rule out pressure ulcers
No history OF IBS rule out PG
NO hx of fracture rule out OM
4-Options are directed to ulcer care and venous reflux
Ulcer care start with need of debridement or not
Venous reflux control options are
Compression therapy alone and it may not heal ulcer or ulcer may recur
Thermal ablation that may be complicated by heat induced skin burns or HIT
Glue that may be complicated by DVT
Surgery that may be complicated by wound problems , pain , or hematoma
I may suggest thermal ablation with phlebectomies if needed.
Good systematic approach, aware of the risk of the intervention, if the ulcer is venous compression dressing alone should heal the ulcer, the role of superficial ablation in venous ulcer is:
1- to shorten the time needed for the healing.
2- to prevent ulcer recurrence after the healing.
with the current immobile status, any venous intervention will carry high risk of DVT which may in turn change the pathology of the ulcer to a post-phlebitic ulcer and these ulcers are. more resistant to healing.
Q1 venous ulcer most probably as same leg vv,young age& i think with paraplegia and wheelchair recumbenance might be more prone for venous stasis
Q2 might also conider- pressure ulcer as site of ulcer not mentioned
also – neuropathic ontop of spinal pathology
Q3 loss of sensation”crude and deep” specially at ulcer dermatome ulcer examination is it regular margin?is it punched out or thing else?hyperemic or ischemic ? skin changes over the limb
Q4 if confirmed venous after full ll neurovasc examination,detailed history and venous duplex ECS can be offered with leg elevation and phsiotherapy if available also local creams for ulcer local perforators can be sclerosed or ligated if direct ulcer relation
Well done, good approach. Only disagreement is with the intervention.
Thx for ur reply i saw ur comment about high risk of dvt i would search for it
Q1: provisional diagnosis>> venous ulcer because
– it is mentioned that it is a leg ulcer not a foot or a heel ulcer which favors venous over ischemic or pressure ulcers
– Hx of VV in the same leg
– The age of the patient (39 years) favors venous pathology over ischemic arterial pathology
– Hx of spinal cord injury and the residual paraplegia with the associated loss of LL muscle tone and muscle pump causing decreased venous return from the LL and increased venous pressure especially with leg dependency as the patient is on wheelchair
– longstanding (one-year duration) non healing ulcer, although this is not specific for venous ulcers
Q2: Other provisional diagnosis >>
– pressure ulcer (bed sore)
– Neuropathic ulcer
– Marjolin ulcer on top of longstanding ulcer
Q3: Signs supporting diagnosis of venous ulcer in the clinical examination :
– ulcer in the gaitre area
– visible varicosities
– skin pigmentations and lipodermatosclerosis around the ulcer
– LL swelling favors venous over arterial pathlogy
– characteristics of the ulcer in the form of sloping edges
– Good distal pulsations to exclude ischemic tissue loss
– Hx of vessel rupture and bleeding from the ulcer
Q4: Management options will be divided into diagnostic options and therapeutic options
1) Diagnostic options:
At first we need to confirm our diagnosis, so I will ask for
– Venous duplex commenting on SFJ&SPJ, deep system, diameter of GSV, incompetent perforators
– Biopsy to exclude malignant transformation if the ulcer shows characteristics of malignant transformation in the form of raised everted rolled out edges
– arterial duplex and ABPI to exclude arterial problem and make sure that the patient can use compression therapies
– CBC, CRP, ESR, Random blood sugar if the patient is not known to be diabetic and HbA1c if diabetic
– culture and sensitivity if the ulcer is infected, although I barely saw infection in venous ulcers and I think I have read that antibiotics have no role in ttt of venous ulcers.
2) Therapeutic options after confirmation of venous ulcer and exclusion of arterial pathology:
Conservative ttt can be offered at first and the patient can be followed up for assessment of ulcer progression
– compression in the form of Crepe bandage or Elastic stockings is the most important element in his ttt after confirming good ABPI
– use of topical debridements creams (like iruxol – hyalo 4 – zymalge) in the daily dressing and use of vaseline gauze on top
– administration of venotonics like diosmin
– leg elevation
– prophylactic anticoagulants as the patient is bed ridden to avoid DVT and post phlebitic syndrome
The patient will be counseled to wear his elastic stocking in the right way by elevating his leg for five minutes while lying in bed before wearing his elastic stocking while still elevating his leg
Other therapeutic options if the patient is not improving
– injection or ligation of incompetent perforators around the venous ulcer
– laser ablation especially in case of incompetent SFJ or SPJ
Well done Muhammed , very systematic and reasonable approach. I will not offer the patient any intervention, as you mentioned he is at high risk of DVT even without intervention. In someone who can walk, i will definitely offer superficial venous ablation + compression. In such scenario, intervention may cause more harm than benefit.
Q1-Venous ulcer secondary to vv as the ulcer in the leg ( may be on gaiter area)
.
Q2-bed sore
May be
.
Q3- it’s C6 so
site of ulcer
Apparent varicose
Long course
Skin color changes
Edema
May ulcer edges as slooped
.
Q4-
I would advise him to
Leg elevation
compression by stocking
Take biopsy for culture and sensitivity
Give him AB according to hospital police
Seeking for home nurse for daily dreesing
May using healing and chemical debridments supported creams like haylo 4 control
..
Or inject feeding vein
…
I will offer him compression
Conservative managemant as less invasive for him
Well done choosing mainly the compression and the conservative treatment, however I was waiting to hear about the other possible causes of ulcer e.g neuropathic due to paraplegia, also in examination I was waiting to hear that arterial assessment is required before offering compression. Ab should not be given unless there are signs of infection.
Ulcer at patient with long duration bed ridden may be
1- venous ulcer 2 ndry to dvt ( as pt has also VV)
2- may be bed sore from epidermal continous compression ischemia
3- may be neurotrophic ulcer 2 ndry to loss sensation
4-may be ischemic ulcer if present over dorsum
5- may be infected ulcer ( tb-sq cc-bcc)(bed ridden pt usualy associated with poor immunity .
Q2
Most probably venous ulcer 2 ndry to long period of bed ridden with appearance of varicosity
Q3
Venous ulcer usualy at gaitre area with slooping edges surrounded by pigmentation and inflammatory process
– bed sores usualy at area of skin with direct contant with ground with necrosis at epidermis,dermis with preserved well circumscriped edges
–
Q4
Treatment include:
Pt advise with leg elevation and repeated turnover
Anticoagulation
Topical antiinflammatory , antibiotics
Surgical debridement
Culture taken
Investigations required :
Duplex scanning for venous and arterial system
X-ray for bone
Hba1c level
Esr-crp
In Q4 may be the question was not clear, I meant based on your provisional diagnosis (single diagnosis), what would be your management.
What is the indication if anticoagulation in this scenario?
If it is venous ulcer, will you give topical anti-inflammatory or antibiotic?
You answered Q2 (venous ulcer), is the your answer in 4 about management of venous ulcer.
Neuropathic ulcer because loss of sensation A pressure ulcer
Other possible diagnosis is venous ulcer
Loss of sensation Will rule out other pathology
Dressing vs
Skin grafting which is the main ttt with risk of recurrence because of sensation loss
I will offer dressing firstly as best option till ulcer is clean and healed
If no improvement skin graft is best option for him
Venous vs neuropathic vs mixed can be the cause.
Loss of sensation does not rule out the other pathology, only presence of pulse and normal ABPI rule out arterial element.
the rest of your plan is sensible.
1- Given the fact that he is bedridden for 5 years My provisional diagnosis will be an ulcer due to compression ischemia
2- yes given the history of varicose veins in the same leg the ulcer could be venous ulcer
3- I will check pedal pulses to role out ischemic ulcer
I will do probe to bone test to role out osteomyelitis as an underlying cause of the ulcer
Also I will check the ulcer charechteristics which can give me an idea about the nature of the ulcer as if the edges are raised and everted it could be malignant ulcer transformation due to the long standing history , if the ulcer surrounding is browny it could be venous ulcer
4- I will start managing this case by doing imaging to reach a proper diagnosis . ABPI OR Arterial duplex us if I cannot deal distal pulses . Venous duplex if it looks like venous ulcer in the gaiter area and even biopsy and the definitive treatment will be according . If it is venous I will offer compression therapy with treatment of underlying cause as perforators or superficial incompetency and if there is no underlying cause I will offer offloading of the ulcer from the bed and
Thank you for your contribution.
1- patient is not bedridden in the scenario. 4 If you considered the patient is bedridden, would you consider venous intervention in such patient?, I disagree with intervention particularly the venous in non-mobile patient due to the high risk of DVT/PE.
A1: the most likely diagnosis is neuropathic pressure ulcer due to the spinal cord injury which caused paraplegia
A2: the other provisional diagnosis could be a venous ulcer because of the varicose veins he had according to the patient’s history
A3: we can examine the ulcer it self regarding the site if it is in pressure areas (neuropathic) or in the gaiter area ( venous), also the ulcer characteristics like edge, margin and base which is specific for the cause as we can see in venous ulcer it shows sloping edge dicoloured surrounding skin irregular margin and red base that could be infected, while in neuropathic pressure sore it shows deep base with punched out edges and painless
A4: the management plan would include some investigations like Doppler US and some neurological tests to clarify the pathology and after that the treatement options will include definitive treatment for the pathology in case of venous cause which may be compression badage, ijection of the ulcer base perforators or venous intervention in the form of ligation and stripping or laser ablation. In case of neuropathy, the treatment is mainly in the form of offloading either surgical or non surgical with air mattress or other offloading tools. The patient should be counseled for the management plan according to the cause and how he controls the risk and causative factors and discuss the role for surgery, compression bandages or offloading methods and the expected time for healing and how to prevent recurrence
Thank you for considering the most common causes of ulcer in this patient.
Neurologic investigation are not required since he is already paraplegic
Venous investigations are not needed since intervention is not the best interest of the patient, only conservative treatment in the form of ulcer care and compression dressing if it is venous.
You missed the arterial assessment in your examination which can be a contributing factor and can prevent you from offering compression.