Chapter 29: Leg Ulcers

INTRODUCTION TO CHAPTER

An understanding of the pathophysiology, diagnosis, and management of leg ulcers is very important to health care providers as these occur in a significant number of patients. Approximately 1% to 3% of the population, or up to 9 million people in the United States are affected.¹ The annual cost of leg ulcers is proposed to be $8 to $10 billion per year, with an estimated loss of 2 million workdays per year.² The majority of leg ulcers are seen in middle-aged to elderly patients, and there is a female:male predilection of 2:1. The three most common types of leg ulcers are venous, arterial, and neuropathic.

VENOUS ULCERS

Introduction

Ulcers caused by venous insufficiency are the most common type of leg ulcerations, accounting for 70% to 80%. They are sometimes called stasis ulcers. About 10% to 20% of leg ulcerations have a mixed venous and arterial etiology. Leg ulcers caused by chronic venous insufficiency lead to significant morbidity and can have a long-term negative impact on an individual's quality of life. Diagnosis can be difficult, and management is often expensive and labor-intensive.

Pathophysiology

Venous ulcers most commonly arise secondary to varicose veins or postphlebitic syndrome. They may also be seen in patients with a history of a deep vein thrombosis (DVT), obesity, or previous leg injury or surgery. When a patient with normal venous return stands or walks, the calf muscle acts in concert with veins and associated valves to empty the venous system and reduce its pressure.³ Venous hypertension develops when the valves become incompetent. This leads to tissue hypoxia and ultimately to skin destruction and breakdown. In addition, wound healing processes are compromised and autolytic processes take action. The result is loss of the epidermis and dermis and the formation of an ulcer.

Clinical Presentation

History

Most commonly, patients complain of a heavy or swollen feeling in the affected leg. Pain ranges from mild with a superficial ulceration to severe with a deep ulceration. Patients may describe limitation of movement of the affected extremity, depending on the location of the ulcer. In addition, patients with venous stasis and dermatitis may have significant pruritus of the skin surrounding an ulcer.

Physical Examination

Most patients with venous ulceration have some degree of nonpitting or pitting edema. Varicosities may be visible, and there is often hyperpigmentation from hemosiderin deposition over the shin. Typically, venous ulcers occur over or proximal to the medial malleolus, but they may occur anywhere below the knee. They can be single or multiple, small or large, shallow or deep. They are usually well marginated with sloped borders, but can present with irregular shapes (Figure 29-1). Often, there is fibrinoid material ...