diagnosis of ulcer

Points	Arterial Ulcer	Venous ulcer	diabetic	neuropathic
pain	Severe(due to tissue ishchaemia) Increases with activity+elevation Wakes up from sleeping Rest pain Intermitten claudication	Dull aching+heaviness(v.HTN+oedema) Increases with dependency(prolong sitting +standing) Decreases by elevation +compression               (bedtime+morning as oedema decreases) severe:infection+art.insufficiency) no pain:neuropathy	Small painless ulcer	Often un noticed (due to secondary trauma    To painless surface)
position	Low ext(distant to travel blood) heel Toe tips-(dorsally & distally),inbet toes Base of fifth metatarsal Ball of the foot Unusual trauma site Rare above knee	Gaiter area Medial aspect of lower leg Medial aspect of ankle Trauma-shin Rare above knee	sole	Susciptible to  trauma sole
periwound	Small shallow punched out Round-regular Dry Edge-steepy Base: Granulation:pale/grey/sloughy Necrotic:yellow(bandage in such a way to maintain hydration) Underlying bone,tendon joint may be seen	Superficial Irregular Moderate to high drainage Edge;White fragile(maceration) Base:beefy red granulation(ruddy appear) Thin glossy film(yellow fibrinogen coating)	Deep punched out painless Pink granulation	Surrounding skin insensate
periwound	Thin shiny dry, hairless Fungal inf(yellow thick brittle) Muscle atrophy(pale,dusky,cyanotic) Dependent rubour Oedema absent    (present:cs may come on wednes day) dependet  rubor	Dermatitis,pruritus Cellulites Low.ext oedema Subtle erythema Dark pigmented skin Lipodermato sclerosis(erythema+induration+plaque)	Prev digital amputation(auto/surgical) Charcot joint Lost foot arch(peri. Neuropathy) Lipoatrophy Necrobiosis lipiodica diabeticorum(erythematous plaque over shin ,waxy,brown pigmentation) Xanthoma(grey yellow paque of lipid in eyelid) Acanthosis nigricans(brown pigmentation in skin fold,axilla) Granuloma annulare(fleshed papule  on extensor of hand and fingers) Feet cold ulcerated discooured Paronychia(poor circulation+immunocompromised)	Surrounding skin insensate
pulses	DPA,PTA(diminished/absent) Capillary refill Doppler USG ABPI toe pressure.measrent	Present Diminished in coexisting arterial disease	Al pulses are intact             But Poor capillary refiling	Good foot pulses             And Good capilary refilling
temp	Cool      Compared foot with prox part       Felt by back of hand	Normal/hot
Examination	All pulses-bilaterally Burger’s test          Upto 90degree-normal           At     50degree-ishchaemia          Below 25degree-critical/rest Allen’s  test ABPI(ankle p. as %of brachial Syst.BP)           >1.1-Diabetic/Renal Failure      0.7-0.9-mild ishchaemia(mixed)       0.4-0.7-moderate           <0.4-critical Capillary refill Hand hold doppler		Neurological examination ABPI=>1.1 Motor:small distal muscle clawing Lost reflexes SENSORY:glove & stocking paraesthesia AUTO:lost sweat             Dry skin             Fissuring              Lost vascular control	Neurological examination
coz	Atherosclerosis(thrombosis/embolus) Thromboembolism(cardiac,aortic,aneurysm) Anomali(popliteal entrapment synd                 Persistent sciatic a.                 Advential cystic disease                 Fibromuscular dysplasia) Inflammatory                  Burger disease                     Vasculitis                      Repeatitive trauma Vasospastic:                      Raynaud’s pheno                       Ergotism                       Drug Hypercoagulable state                        Polycythaemia                        Thrombocytosis                         Malignancy                         Protein C/S def Atheroscerosis-large artery DM-large+ small arteriole Large-embolism Small-raynaud’s,burger’s,scleroderma,	Venous stasis	DM	i.Peripheral neuropathy       DM,Leprosy,nerve injury ii.spinal cord lesion         spina bifida          tabes dorsalis          syringmyelia
Inv:	CBC RBS,FBS,2HABF,HbA1C Fasting Lipid Profile S.Creatinine,B.Urea,Electrolytes ECG,Echo Contrast Angiography(for planning of Intervention) MRA
	Conservative: avoid         smoking         fat improve walking distance regular ASPIRIN(45mg) daily Local Care:         Regular dressing         Non adherent dressing         Avoid compression bandage         Topical antiseptics Surgical:          Angioplasty(young adult)           Bypass                      Critical ishchaemia                       Rest pain                       Tissue loss               (bone-tendon    exposed)           Amputation                       Small vessel disease                        Diabetic                        Infection                        gangreene	Duplex doppler               Arterial-inv+Rx of insufficiency               Venous                      i.superficial- sugery                      ii.deep-COMPRESSION                                           BANDAGE for 12 wks (3 layers=30mmHg, 4 layers= 45mmHg) ABPI     >0.9-venous-full compression ABPI 0.7-0.9-mixed –light compression+Revasculariza If   Healing-Rx continue   Non Healing-Excision Grafting(skin/pinch split)                         Follow up after 12 wks If still not healing think as NON HEALING Ulcer             i.marjolins(over malleoli with raised edge bleeds easily)             ii.Vasculitis     Debrimentation +culture sp syst Antibiotic(never topical) fld by Compression Bandage for 12 wks Infected: Debrimentation +culture sp syst Antibiotic(never topical) Thrombophlebitis:elevation+ NSAID Indication of skin split graft     ABPI>0.5     >10sq cm lesion	Patient education Good control of DM Wear accommodative footwear(soft leather) Nail and skin care Surgery: Amputation                    Metatarsal                     toe              Medical Rx:     Aspirin      Oxpentaphylline      PGE1 analogue      Diaosmine-500mg SURGICAL: Deep wound-    Debrimentation Culture and specific antibiotics /partial amputation	Debriment and offloading of pressure