Vascular, Lymphatic and Integumentary Disorders Module 1

What is an arterial ulcer?

Wound caused by poor blood flow (ischemia) due to arterial disease

Where are common locations for an arterial ulcer?

Toes, feet or lower legs (distal extremities)

What is a Venous ulcer?

Wound caused by poor venous return (blood to heart)

Where are common locations for venous ulcers?

Lower leg around the ankles

What is a Neuropathic ulcer?

Wound caused by peripheral neuropathy

Where are common locations for Neuropathic ulcers?

Plantar surface of foot over pressure points

What is a Lymphatic ulcer?

Wound that develops due to impaired lymphatic drainage usually accompanied by edema

Where are common locations for Lymphatic ulcers?

Lower extremities

What is Arterial Insufficiency?

Lack of adequate blood flow to a body region

What is Peripheral Vascular Disease?

General term for disorders that interfere with blood flow to the extremities (arterial or venous)

Peripheral Vascular Disease is caused by Arterial Insufficiency related to…

Smoking
Diabetes
Hypertension
Renal Disease
Elevated Cholesterol or Triglycerides

What is Arteriosclerosis?

Thickening and hardening of arterial walls

What is Atherosclerosis?

A common type of arteriosclerosis caused by a buildup of plaque inside arteries

What is the Desirable, Borderline and High Risk levels for Cholesterol?

<200 mg/dl
200-239 mg/dl
240 mg/dl

What is the Desirable, Borderline and High Risk levels for Triglycerides?

<150 mg/dl
150-199 mg/dl
200-499 mg/dl

What is the Desirable, Borderline and High Risk levels for HDL cholesterol?

60 mg/dl
35-45 mg/dl
<35 mg/dl

What is the Desirable, Borderline and High Risk levels for LDL cholesterol?

60-130 mg/dl
130-159 mg/dl
160-189 mg/dl

What is the Desirable, Borderline and High Risk levels for Cholesterol/HDL ratio?

4.0
5.0
6.0

What is Arteriosclerosis Obliterans?

A severe form of arterial insufficiency where the arteries in the legs become thickened, narrow and occluded

What is Arteriosclerosis Obliterans characterized by?

Intermittent claudication
Rest pain
Trophic changes

How is Arteriosclerosis Obliterans managed?

With vitamin B6, vitamin B9 and vitamin B12 supplementation

What is Thromboangiitis Obliterans (aka Buerger’s Disease)

Inflammatory condition of arterial occlusion (blood vessels blocked) that leads to tissue ischemia (necrosis) of the hands and feet

Thromboangiitis Obliterans is most common in what population?

Young men who smoke

What is Raynaud’s Disease?

Vasomotor disease in which small arteries temporarily constrict in response to cold or stress, causing color changes, numbness, tingling in pain in the hands or feet

What is Arterial Ulceration?

Wound that occurs due to insufficient arterial blood flow to tissues, leading to ischemia and necrosis

True or False: 10-25% of LE ulcers are caused by arterial disease

True

What is the typical wound location in the LE for an individual with Arterial Insufficiency?

Lateral malleoli
Dorsum of foot
Toes

True or False: Majority of patients with arterial Insufficiency have diabetes

True

What are some trophic changes associated with Arterial Insufficiency?

Abnormal hair growth
Decreased hair on the leg/foot
Dry skin

What is the clinical presentation of Arterial Insufficiency wounds?

Skin is cool
Wound base is necrotic, pale and lacks granulation tissue
Skin around the wound is black or mummified

For patients with Arterial Insufficiency, a common complaint is intermittent claudification. What is that?

Exercising the muscles not receiving blood perfusion, such as walking, causes painful aching or cramping

What is the Ankle Brachial Index?

Provides Ankle/Brachial Pressures via Doppler Ultrasound

What does an Ankle Brachial Index (ABI) Range of >1.2 indicate?

Possibly Falsely elevated, Arterial Disease, Diabetes

What does an Ankle Brachial Index (ABI) Range of 1.19-0.95 indicate?

Normal

What does an Ankle Brachial Index (ABI) Range of 0.94-0.75 indicate?

Mild Arterial Disease + Intermittent Claudication

What does an Ankle Brachial Index (ABI) Range of 0.74-0.50 indicate?

Moderate Arterial Disease + Rest Pain

What does an Ankle Brachial Index (ABI) Range of <0.50 indicate?

Severe Arterial Disease

True or False: If a patient has an arterial ulcer, compression and debridement is appropriate interventions

False; never compress an arterial insufficiency

True or False: Necrotic tissue should not be debrided

True (dead tissue will not be replaced with new tissue)

True or False: Appropriate interventions for arterial ulcers include skin grafts, antibiotics and topical agents

False
Skin grafts do not adhere to lifeless wound beds
Antibiotics can’t reach the wound systemically
Topical agents are too superficial to reach infection

What is the best intervention (surgical) for an arterial ulcer?

Vascular surgery to restore arterial circulation to ischemic tissue OR amputation

What is Venous Insufficiency?

Inadequate drainage of venous blood from a body part, resulting in edema, skin abnormalities and ulceration

What is Chronic Venous Insufficiency (CVI)?

Venous insufficiency persisting for long periods of time

What is the most common cause of leg ulcers?

Venous insufficiency

True or False: 80% of leg ulcers are caused by venous disease

True

What are some factors predicting ulcers due to venous insufficiency

Number of pregnancies
Long hours of standing or sitting
History of DVT
History of vigorous activity in presence of other factors

What is the clinical presentation of venous insufficiency?

Swelling of unilateral or bilateral leg with complaints of itching, fatigue, aching and heaviness of the limb

What are some skin changes that can occur with Venous Insufficiency?

- Hemosiderin staining (brownish discoloration of the skin)
- Lipodermatosclerosis (inflammed skin thats hyperpigmented)
- increased lower leg temperature

Where are ulcers due to venous insufficiency typically located?

In the LE proximal to medial malleolus but can occur anywhere (like arterial wounds)

What are complaints associated with Venous Insufficiency?

Minor leg pain that is relieved by elevation

What does a venous insufficiency wound look like?

Granulation tissue present
Tissue is wet from excessive exudate
Lymphedema may be present

True or False: Venous wounds can exist for years and symptom progression can lead to development of lymphedema

True

What is the test and measurements behind Venous Insufficiency?

Address the possibility of arterial component to venous pathology

True or False: For venous insufficiency, it is safe to use compression unless arterial insufficiency is also present

True

For Venous Insufficiency, if the skin temperature of the lower legs become elevated what could this imply?

Worsening or impending complication of CVI

What is the most important therapeutic intervention measure for prevention and treatment of Venous Insufficiency?

Compression therapy, wound care, exercise and positioning

Arterial or Venous:
Location is the dorsum of foot, toes and lateral malleoli

Arterial

Arterial or Venous:
Location is the medial malleoli

Venous

Arterial or Venous:
Wound base is Gangrenous

Arterial

Arterial or Venous:
Wound base is Granulating

Venous

Arterial or Venous:
Wound edge is punched out, defined

Arterial

Arterial or Venous:
Wound edge is diffuse, not well defined

Venous

Arterial or Venous:
Skin temperature is cool

Arterial

Arterial or Venous:
Skin temperature is warm

Venous

Arterial or Venous:
Exudate not present, dry wound

Arterial

Arterial or Venous:
Lots of exudate

Venous

Arterial or Venous:
ABI range is abnormal

Arterial

Arterial or Venous:
ABI range is normal without arterial insufficiency

Venous

Arterial or Venous:
Pain is worse with leg elevation

Arterial

Arterial or Venous:
Pain is better with leg elevation

Venous

Arterial or Venous:
Leg compression is contraindicated

Arterial

Arterial or Venous:
Leg compression is hallmark of treatment

Venous

Arterial or Venous:
Leg edema is not present

Arterial

Arterial or Venous:
Leg edema is present

Venous

Arterial or Venous:
Intermittent claudication is present

Arterial

Arterial or Venous:
Intermittent claudication is not present

Venous

What is Neuropathy?

Disease of the nerves

True or False: Neuropathy associated with most chronic diseases, including diabetes, the effects are peripheral

True

What is Diabetic Neuropathy?

Diabetes mellitus related disorder of nerves

What percentage of individuals with diabetes develop an ulcer some time in their life

15%

Patients with diabetic neuropathy are __ times more likely to have an amputation due to a non healing wound

40

True or False: 60% of non-traumatic amputations are due to diabetes

True

What is the typical location on the body where a neuropathic wound is found

Weight bearing surfaces (plantar foot)

If sensory neuropathy is present, the patient is…

unable to sense pain or pressure

What is the clinical presentation of a Neuropathic wound?

Dry
Callus formation
Round
Over a bony prominence

In diabetic neuropathy, what is the clinical presentation if motor neuropathy is present

Loss of intrinsic muscles
Hammer toe or claw toe deformities

In diabetic neuropathy, what is the clinical presentation if autonomic neuropathy is present

Decreased or absent production of sweat and oil; heavy callus formation

In addition to diabetic neuropathy, if a dysvascular symptom (arterial disorder) is present, what becomes impaired?

O2 transport
Nutrient transport
Antibiotic transport

Hemoglobin A1c is a good value to determine diabetes. What is the normal, prediabetes, and diabetes levels?

Normal: <5.7%
Pre-Diabetes: 5.7-6.5
Diabetes: >6.5%

What is the normal values for fasting, after eating, and 2-3 hours after eating of Blood Glucose?

Fasting: 80-100
After Eating: 170-200
2-3 Hours After Eating: 120-140

What is the impaired glucose values for fasting, after eating, and 2-3 hours after eating of Blood Glucose?

Fasting: 101-125
After Eating: 190-230
2-3 Hours After Eating: 140-160

What is the diabetic values for fasting, after eating, and 2-3 hours after eating of Blood Glucose?

Fasting: 126+
After Eating: 220-300
2-3 Hours After Eating: 200+

What are important tests and measures for individuals with Diabetic Neuropathy?

Check protective sensation
Skin temperature should be recorded

How can PT’s reduce the incidence of ulcers in patients with Diabetic Neuropathy?

Education
Comprehensive Foot Care