Leg ulcers: Clinical

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Leg ulcers: Clinical

USMLE® Step 2 questions

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USMLE® Step 2 style questions USMLE

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 A 34-year-old man presents to the emergency department for evaluation of pain in the right lower extremity. The patient was running on the beach without shoes over the past weekend and sustained a small laceration to the bottom of the foot. Over the past 24 hours, he has been experiencing severe pain and swelling of the foot to the point that he is unable to bear weight. He is otherwise healthy and does not smoke, consume alcohol, or use illicit substances. Temperature is 38.6°C (101.5°F), pulse is 109/min, respirations are 22/min, and blood pressure is 131/72 mmHg. On physical examination, a 3 cm x 3 cm area of erythema is noted on the underside of the right foot. The patient is exquisitely tender to palpation over the entire aspect of the right foot extending to the mid tibia. A radiograph of the right foot is obtained and demonstrates the following finding:

Reproduced from: Radiopaedia

Which of the following is the most appropriate treatment for this patient’s clinical condition?  


An ulcer is an unhealed sore or open wound that may appear on the skin or mucosal surfaces due to destruction of the epidermis that extends into the dermis and may reach subcutaneous fat or deeper tissues.

Skin ulcers may take a very long time to heal. For optimal wound healing, the wound bed needs to be well vascularized, free of devitalized tissue, clear of infection, and moist.

The general approach to treating any ulcer starts from wound debridement to remove the accumulation of devitalized tissue, as well as decreasing the bacterial load to prevent infections.

This is usually done through irrigation, typically warm isotonic saline solution; while surgical debridement with a scalpel or other sharp instruments is done for removing large areas of necrotic tissue, for chronic non healing ulcers, or when there are signs of infection.

In addition, individuals with infected ulcers should have wound cultures sent and should get started on antibiotic therapy.

Then, a dressing is applied to the ulcer to help the wound heal more quickly by providing a sterile, breathable and moist environment, as well as reducing the risk of infection. Dressings are typically changed daily or every other day.

Nonhealing ulcers may progress to gangrene, which is a hard, dry texture, usually in the distal toes and fingers, often with a clear demarcation between viable and black, necrotic tissue.

When gangrene has set in, aggressive debridement or amputation of the affected area may be required.

Skin ulcers most often appear on the legs, and can result from multiple causes.

Biopsies are not usually necessary for most ulcers, but can be helpful when the diagnosis is uncertain.

The most common causes are venous insufficiency, arterial insufficiency, and neuropathy. So they’re often classified as venous, arterial, or neuropathic.

Venous ulcers are associated with venous insufficiency due to valve dysfunction, which causes stasis of blood in the legs, and that leads to an increase in venous pressure. This in turn allows blood proteins and fluid to leak into the interstitial space.


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