LOWER LIMB ULCERATION
A 50-year-old man presents to the vascular clinic with an ulcer on the lower aspect of the left leg. It appeared 3 months ago following minor trauma to the leg and has grown in size steadily. There is no other past medical history of note.
There is an ulcer, shown in Figure, with slough and exudate at the base. There is surrounding dark pigmentation. Examination of the rest of the leg shows varicose veins in the long saphenous distribution.
• What is the definition of an ulcer?
• What are the causes of ulceration?
• What else should be included in the examination and investigation for lower limb
• What does the management of a venous ulcer involve?
• How should the patient be managed once the ulcer has healed?
An ulcer is the dissolution of an epithelial surface. This patient has venous ulceration.The ulcer is situated in the medial gaiter region. The edges slope and the base has healthy tissue. The surrounding skin changes support a venous aetiology.
Causes of leg ulceration !
• Mixed venous/arterial
• Diabetic: underlying aetiology neuropathic/arterial or mixture of both
• Sickle cell
• Pyoderma gangrenosum
During examination, peripheral pulses should be palpated and Doppler pressures obtained.Investigations include full blood count and erythrocyte sedimentation rate, autoantibodies(if there is a possibility of rheumatoid vasculitis) and blood glucose levels.
The mainstay of treatment for venous ulcers is calf pump compression using multi-layered bandages applied to the lower leg. The ulcer is inspected weekly to ensure that it is healing,and bandages are re-applied. An ulcer that fails to heal with these measures may benefit from surgical debridement and the application of a mesh skin graft. Malignant transformation
(Marjolin’s ulcer) can develop in a long-standing, non-healing venous ulcer.
Once the ulcer has healed the superficial and deep veins of the leg should be assessed using a duplex Doppler scan. Saphenous vein surgery should be considered if there is evidence of sapheno-femoral or sapheno-popliteal reflux with patent deep veins. This can prevent recurrences. Patients who do not undergo surgery should wear graduated elastic support
stockings to prevent recurrence.
• Venous ulceration should be treated with compression bandaging.
• Caution should be taken in patients with peripheral arterial disease.