LOWER EXTERIMITY ULCERS

Definition
Lower extremity Ulcers are wounds or open sores that will not heal or keep returning that may or may not
be painful in the lower extremity. The patient generally will has a swollen leg and may feel burning,
itching, rash, redness, brown discoloration or dry, scaly skin.
There are three most common types of leg and foot ulcers:

Venous statis ulcers

Neurotrophic (diabetic)
Arterial (ischemic ulcers)

They are typically defined by the appearance, location, and the way the borders and surrounding skin of the
ulcer look.
Etilogy

Poor circulation, often caused by arteriosclerosis

Venous insufficiency (a failure of the valves in the veins of the leg that causes congestion and

slowing of blood circulation in the veins)

Other disorders of clotting and circulation that may or may not be related to atherosclerosis
Diabetes
Renal (kidney) failure
Hypertension (treated or untreated)
Lymphedema (a buildup of fluid that causes swelling in the legs or feet)
Inflammatory diseases including vasculitis, lupus, scleroderma or other rheumatological conditions
Other medical conditions such as high cholesterol, heart disease, high blood pressure, sickle cell

anemia, bowel disorders

History of smoking (either current or past)
Pressure caused by lying in one position for too long
Genetics (ulcers may be hereditary)
A malignancy (tumor or cancerous mass)
Infections
Certain medications

Pathophysiology
Endothelial cell dysfunction and smooth cell abnormalities develop in peripheral arteries as a consequence
of the persistent hyperglycemic state. There is a resultant decrease in endothelium-derived vasodilators
leading to constriction. Further, the hyperglycemia in diabetes is associated with an increase in
thromboxane A2, a vasoconstrictor and platelet aggregation agonist, which leads to an increased risk for
plasma hypercoagulability. There is also the potential for alterations in the vascular extracellular matrix
leading to stenosis of the arterial lumen. Moreover, smoking, hypertension, and hyperlipidemia are other
factors that are common in diabetic patients and contribute to the development of PAD. Cumulatively, this

leads to occlusive arterial disease that results in ischemia in the lower extremity and an increased risk of
ulceration in diabetic patients.
Clinical Manifestations
History:
Claudicating pain
Rest pain, night pain
Non-healing, painful ulceration
Findings:

Cold limb or feet

Shiny, atrophic skin
Hairless
Painfull
Dependent rubor
Elevation pallor
Dry gangrene, punched-out ulcer of toes or over bony prominence

Table1. Clinical manifestation of arterial ulcers

Picture1. Example of an arterial ulcer

Arterial Insufficiency
Diagnosis Non-Invasive Studies:
Ankle brachial index (ABI)
o 0.5 0.8: peripheral arterial occlusive disease

o >1.2 suggests noncompressibility, need TBIs

o <0.4: severe ischemia
Toe brachial index (TBI)
o <30 mmHg systolic pressure: severe ischemia
Treatment
Diagnose level of arterial insufficiency:
o Segmental pressures, pulse volume recordings
Arteriography +/- endovascular treatment
Open surgical bypass
Medication Management
Wound Care: surgical debridement, amputation;
o Dry dressing or open to air
o No ointments or creams
o Minimal to no debridement
o Pressure relief
o Infection control
Post-Intervention:
o Keep dry until eschar gone, may trim edges
o For pink wound base, keep moist
o Accommodate wound
o Smoking cessation
o ASA and statin therapy
o Exercise
o Vascular surveillance after procedures