Approach

• Expose limb

1. Inspection

   

   • Site - over tips of toes / pressure areas
   • Shape - highly variable
   • Edge - punched out / clean (no partial healing)
   • Base - contains slough and may be infected, no healthy granulation tissue
   • May be deep down to bone and underlying joint
   • Skin: grey/blue colour
2. Palpation
   • Temperature using back of hands: note surrounding skin cold compared with proximal limb and contralateral foot
   • Check peripheral pulses
   • Check pulses of other leg
3. Percussion
4. Auscultation

Causes of ischaemic ulcers

1. Large vessel disease
   • Atherosclerosis
   • Thromboangiitis obliterans
2. Small vessel disease
   • Diabetes mellitus
   • Polyarteritis nodosa
   • Rheumatoid arthritis

Analgesia available for patient

• Ischaemic ulcers are painful
• Consider analgesic ladder

Management

1. Non-surgical
   • Risk factor modification - stop smoking, good DM control, BP control, optimized serum lipid levels
   • Symptom modification: avoid B-blockers
   • Low dose aspirin
   • IV prostaglandins: inhibit platelet aggregation
   • Lumbar sympathectomy reduces sympathetic-mediated vasoconstriction and improves perfusion by allowing unopposed vasodilation of skin vessels
2. Surgical