 Classification

 Vascular
Arterial
Atherosclerosis
Buerger’s Disease
Vasculitis
Raynaud’s Disease

Venous
Chronic venous insufficiency
Varicose Veins
Post Sclerotherapy

Lymphatic
Chronic Lymphodema
 Infective

Pyogenic
Osteomyelitis
Synergistic Gangrene
Syphilis
Tuberculosis
Tropical Diseases
Fungal Diseases
 Traumatic
Radiation
Thermal Burns
Decubitus
Bites
Mechanical

 Neoplastic
Melanoma
SCC/BCC
Metastatic
Kaposi’s Sarcoma
 Systemic-Metabolic
Ulcerative Colitis
Diabetes
Sickle Cell Disease
Avitaminosis

 Neurotrophic
Cord Lesions
Periph Neuropathies
Trauma
Diabetes
Tabes dorsalis
Alcoholism
 History
◦ Precipitating event
◦ Duration
◦ Symptoms
◦ Systemic features
◦ Risk factors
◦ Peripheral ischaemic symptoms
◦ Previous interventions
◦ Treatment
 Arterial
Chronic ischaemic symptoms
Claudication/rest pain
Risks
Hypertension, smoking, cholesterol, diabetes,
exercise
◦ Previous arterial interventions
 Venous
◦ Varicose veins
◦ DVT/thrombophlebitis
◦ Previous ulceration
◦ Previous treatments
◦ Sclerotic changes
◦ Oedema
◦ Painless
 Vasculitis
◦ History of autoimmune disease
◦ Painful
◦ Lack chronic arterial occlusive symptoms
◦ Systemic symptoms of autoimmune disease
 Infective
◦ Exposures
◦ Associated cellulitis
◦ Systemic symptoms
◦ Exudate
 Neoplastic
◦ Chronicity
◦ Previous malignancy
◦ Risks
 Exposures
 UV radiation
 Ionising radiation
Distribution VenousGaiter Area
Arterial Lateral
Web Space
Pressure Areas
Traumatic Subcutaneous Brdrs
Site of trauma

Size VenousLarge Shallow

Arterial Small Deep
Traumatic Variable

Character VenousShallow, Irregular

Arterial Deep, Punched out
Traumatic Variable
Base VenousGranulating
Arterial sloughy
Traumatic variable

Edges Sloping
Punched out
Undermined
Rolled
Everted

Discharge Serous
Serosanguinous
Purulent
Associated Findings

Arterial Atrophic Skin & Nails

Poor capillary return
Beurger’s angle
absent pulses, thrills, bruits

Neurological abnormalities

Venous pigmentation
eczema
lipodermatosclerosis
varicose veins

Other Regional lymphadenopathy

Neovascularisation
Cellulitis
Scars from previous ulceration
Signs of CCF
The Aim of Investigation
To identify Causative Factors
Factors inhibiting healing

General Investigations
Haematological FBC
U&E, LFT’s
Gluc
CRP

Other ECG
X Ray
Swab MC&S (remember TB)

Specific RF, ANA DNA binding

Compliment Levels
Specific

Arterial ABI’s
Duplex
DSA

Venous Duplex Incompetence SFJ

SPJ
Perf.
DVI
Thrombus
Plethysmography

Other Biopsy
Ix causes of trauma
 Dressings
◦ Encourage healing
 Moist
 Reduce oedema
 Remove pathogens
 Protect healing tissue
 Debride
 Necrotic tissue
 Slough
 Foreign bodies
 amputation
 Vascularise
 Angioplasty
 Bypass
 Optimise cardiac circulation
 Eliminate venous hypertension
 Varicose vein surgery
 Venous valve replacement
 Sclerotherapy
 Venous bypass
 Treat infection
 IV/oral antibiotics
 Topical - acetic acid/SSD
 Antifungal
 Wound closure
 Secondary intention
 SSG
 V.A.C.
 Plastic surgery flaps
 Systemic treatment
 Steroids
 Diet
 Trace elements
 Avoid cross contamination
 sunlight
 Aetiology
Trauma
Iatrogenic
Non iatrogenic
Embolic
AF
Atheroembolic - aortic/aneurysm

Thrombosis - popliteal/stenotic segment

Venous ischaemia
 Presentation

◦ Pale
◦ Painful
◦ Pulseless
◦ Paralysed
◦ Perishingly cold
◦ Parasthesia
◦ Calf tenderness

 Time critical
 Aetiology
◦ Atherosclerotic
 Diabetes
 Renal failure
 Smoking
◦ Buerger’s disease
◦ Vasculitis
◦ Arterial trauma
◦ Popliteal aneurysm disease
◦ Popliteal artery entrapment
◦ Cystic adventitial disease of popliteal artery
◦ Hyperhomcysinaemia
 Presentation
Asymptomatic
Claudication
Subjective/individual variation
Rest pain
Tissue loss
 Examination

◦ Pulses
◦ Temperature
◦ Capillary return
◦ Trophic changes
 Hair loss, nail changes, thin shiny skin
◦ Ulceration
◦ Gangrene
◦ Surgical scars - vein harvest/strip
◦ Pallor on elevation
 Risks

◦ Diabetes
◦ Venous sclerosis
◦ PVD
◦ Ulcers
◦ Lymphoedema
 Bacteriology
◦ Streptococcal - small skin breaks, fever, usually
group A
◦ Staphlococcal - larger wounds, ulcers or abscess
◦ Haemophilus influenzae - periorbital cellulitis
◦ Exogenous bacteria
◦ Cat bite - pasturella multocida
◦ Dog bites - Staph intermedius
◦ Fresh water cuts - Aeromonas hydrophilia
◦ Fish tank exposure - Mycobacterium marinum
 Management

◦ Investigation -
 Blood and wound cultures, Xray, nuclear medicine scan,
arterial and venous investigation
◦ Antibiotics
◦ Rest and elevate
◦ Treatment of cause
◦ Systemic symptoms - admission
◦ Foot care/pressure care