Leg ulcers
A leg ulcer is a loss of skin tissue usually originating from an arterial or venous circulatory disorder.
Other causes such as diabetic ulcers, angio-necrotic ulcers, blood diseases or cancers, are more unusual.
- The prevalence of leg ulcers is estimated to be 1% of the general population and increases with age, reaching 3% of the population aged 65 years or more.
- The proportion of ulcers with a mixed arterial-venous origin has increased during the past few decades, as a result of the ageing of patients suffering from these diseases.
- Ulceration does not tend to heal spontaneously.
- It is a genuine problem due to its incapacitating nature and its cost for society.
- It can also lead to complications such as infection.
Leg ulcers (read more...)
A distinction is made between ulcers of venous and arterial origin
VENOUS OR MIXED LEG ULCER
There are two main types of venous ulcers: varicose ulcers and post-phlebitic ulcers.
- Venous leg ulcer
This is the most common type of leg ulcer. It can occur at an earlier or later stage following a deep vein thrombosis or a varicose disease with leaking perforating veins.
The main biological characteristics of superficial ulcers are:
Lack of pain, the location around the malleolus, a wet appearance and the co-existence of skin disorders caused by chronic venous insufficiency (pigmented purpuric dermatitis, sclerous hypodermitis, atrophie blanche, etc.).
Lack of necrosis, presence of peripheral pulse.
- Mixed leg ulcer = Caused by a combination of both arterial and venous insufficiency.
An arterial ulcer is the consequence of arterial circulatory insufficiency, causing peripheral ischemia.
- Post-phlebitic ulcer
30 to 50% of all venous ulcers are post-thrombotic. Deep venous trunks are affected, unlike the varicose ulcer. Post-thrombotic syndrome develops gradually and will continue to deteriorate if serious treatment is not actioned.
These ulcers are becoming less frequent due to improved good prevention of phlebitis over the last 15 years.
However, venous ulcers are becoming increasingly complicated due to arterial involvement and to an increase in the average age of patients suffering from them. For this reason, an arteriograph should be performed immediately on people suffering from an ulcer which does not respond to well-managed treatment (compression stockings, appropriate dressings).
ARTERIAL LEG ULCER
Arterial leg ulcers are less common. Their main biological characteristics are their painful nature, exacerbated by raising the limb to a horizontal position, the distal or “suspended” location away from the malleolus, the necrotic and deep appearance, the exposure of underlying structures, the atonic base, the sharp edges of the wound and the coexistence of signs of arterial insufficiency.
PERIPHERAL ARTERIAL DISEASE OR ARTERITIS
The origin of the development of a thrombosis is an atheromatous plaque.
Arterial disease occurs mainly in male smokers over the age of 50 years old.
A replacement collateral circulation develops when the main arteries are affected, however, this circulation is not always sufficient to satisfy the oxygen requirements of the active muscles in action.
The development of the condition has 4 stages:
| Stage I | Slight cooling of the feet with slight cyanosis of the lower limbs. The doctor may observe a reduction or elimination of the pulse. |
| Stage II | Pain develops while walking, and cramp-like pains forces the patient to stop and rest. The result is a defined walking perimeter and the term intermittent claudication is used. |
| Stage III | The ischemia becomes severe, pain continues even when resting, and can also occur when the patient is supine. |
| Stage IV | Circulation is interrupted. Trophic disorders and ulcers appear. There is a risk of gangrene if left untreated. |
The basic treatment for peripheral arterial disease is to surgically restore arterial circulation. Surgery may involve unblocking the arterial lumen or bypassing the blockage.
Diagnosis of an arterial ulcer and a venous ulcer (read more...)
Clinical characteristics:
- The Location
Venous ulcers are usually located on the lower limb above or in the malleolus.
An ulcer with arterial origin is mostly located on the foot.
- The size, shape, depth and appearance of the base and the edges of the ulcer
- The appearance of the skin around the ulcer
Oedema can sometimes affect the entire leg, combined with skin inflammation. Examination of the ulcer must be accompanied by an examination of the leg and a holistic assessment, concentrating specifically on the cardiovascular system, nutritional status and the patient's mobility.
Additional tests
Assessment of the condition of the vascular system will give information about blood perfusion in the lower limbs and concerns the narrow arterial, venous and micro-circulation component. These examinations provide additional essential information complementary to the clinical examination.
| Continuous Doppler Continuous Doppler ultrasound is an haemodynamic examination that provides information about the venous system and the arterial system. |  |
| Ultrasonography Ultrasonography provides a view of vascular structures and describes them. The vascular lumen, calibre and contours of the wound are measured. |  |
| Arteriography Arteriography is essential before any surgical operation to determine the exact point of a blockage. This is an X-ray examination that displays arteries following injection of an iodine contrast solution into them. |  |
