A 68-year-old woman with a leg ulcer

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Problem 25 A 68-year-old woman with a leg ulcer

Robert Fitridge

A 68-year-old woman attends the outpatient department with an ulcer on her left leg. She tells you it has been present for 2 months. She remembers knocking her leg on the end of her bed. The ulcer on her leg has become fairly painful over the last week. She has had a similar ulcer on her leg in the past which was treated by ‘bandaging’.

Q.1

What other information would you like from the history to ascertain the cause of the ulcer?

She is not a diabetic, but does take tablets for her blood pressure. She is not sure what these are. She is on no other medications. She has had no other illnesses of note, but has had varicose veins ever since the birth of her children. On further questioning, she reveals that the left leg was very swollen for 2 or 3 months after her third pregnancy but she never had any tests to see why. This has been her ‘bad leg’ ever since. Her leg ulcer is shown in Figure 25.1.

image

Figure 25.1

Q.2

Describe what you see.

In addition to what is shown in the photograph, both legs show evidence of chronic venous insufficiency. There is loss of subcutaneous fat, and this atrophy has caused an ‘inverted champagne bottle appearance’. There is pigmentation above each ankle. There are no ulcers on the feet or toes.

Q.3

What else are you going to look for before you complete your examination of her legs?

On general examination she is mildly obese and has a blood pressure of 160/110 mmHg. The rest of the cardiorespiratory and abdominal examination is unremarkable. Her left leg shows varicosities in the distribution of the long saphenous vein. The right leg is similarly affected with varicosities and changes of chronic venous insufficiency in the lower third of the calf. You note the skin around the ulcer is mildly inflamed and tender and you think the ulcer is infected. The peripheral pulses and neurological exam of the lower limbs are normal.

Q.4

What is your diagnosis now? What, if any, investigations should be performed? What is your initial management?

Answers

A.1 You would like to know if there is a history of:

• Varicose veins or deep venous thrombosis.
• Previous surgery on this leg.
• Pain in the lesion.
• Problems with her legs suggestive of arterial insufficiency, e.g. claudication, rest pain.
• Diabetes mellitus.
• Rheumatoid arthritis or other vasculitic process.

You also want to know the patient’s general state of health, and occasionally their place of origin (tropical ulcers). You would also want to know about other medical problems like cardiovascular disease, renal disease, what medication she takes (e.g. steroids) and use of tobacco and alcohol.

A.2 There is an extensive ulcerated area over and above the medial malleolus approximately 8 × 5 cm. There is slough on the ulcer but with considerable healthy granulation tissue. The surrounding skin is discoloured, scaly and indurated. There are areas of haemosiderin deposition. This appearance is characteristic of venous ulceration secondary to chronic venous congestion.

A.3 On examination you need to ensure that pulses are present in the limbs (i.e. palpable femoral, popliteal and at least one of the dorsalis pedis or posterior tibial pulses). It is also important to exclude neuropathy by performing a screening neurological examination of the lower limbs.

A.4 The diagnosis is a venous ulcer. In the presence of cellulitis, take a swab and start antibiotics to cover Staphylococcus aureus, streptococcus and Gram-negative bacilli including E. coli and Klebsiella.

A venous incompetence duplex scan is not essential in this setting but will confirm underlying incompetence of the deep veins (usually secondary to a previous DVT) in approximately 40–50% of cases, or of the superficial veins (long or short saphenous ± perforating veins) in a further 40–50% of cases. Some individuals may have incompetence of both deep and superficial venous systems.

Initial management is based on compression therapy. You may delay commencing this for a few days until the cellulitis has settled. Most frequently, a four-layered compression bandaging system is applied on a weekly basis until the ulcer is healed. Smaller ulcers can be managed with occlusive dressings and class III (30–40 mmHg) compression stockings. Most clinicians use knee-high rather than full-leg stockings because of higher patient compliance levels. Many clinicians use class II (20–30 mmHg) knee-high compression stockings in elderly patients as compliance is better with these stockings.

Once healed, compression is maintained using knee-high stockings to reduce recurrence. Patients with isolated venous incompetence of the superficial systems (e.g. long saphenous vein ± perforator incompetence, with normal deep veins) should be considered for surgery or endovenous ablation of incompetent superficial veins to reduce the risk of recurrent ulceration. Skin grafting is infrequently required in venous ulcers.

In this patient healing will take many weeks. Therefore, she will require visits from a nurse who is experienced in wound care and assistance in the activities of daily living.

Revision Points

Assessment of Leg and Foot Ulcers

Table 25.1 describes the assessment of these ulcers. Note:

• Vasculitic ulcers: exclude above causes, may need biopsy.
• Malignant ulcers: biopsy suspicious ulcers and those not responding as expected.
• Combination of above aetiologies common.

Table 25.1 Assessment of leg and foot ulcers

image

Issues to Consider

• What advice can be given to diabetics with neuropathy to avoid lower limb ulceration?
• What is the cause of tropical ulceration?
• What are the features of the various dressings available to specialist teams to manage lower limb ulceration?
• Why do varicose veins form and what are the associated complications?
• Do varicose veins predispose to deep vein thrombosis?
• How can chronic venous insufficiency be treated surgically?

Further Information

London N.J.M., Donnelly R. ABC of arterial and venous disease: ulcerated lower limb. British Medical Journal, 320. 2000:1589-1591. www.bmj.com. A superb overview of the subject

www.thediabeticfoot.net. An interesting resource about diabetic foot care

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Problem 25 A 68-year-old woman with a leg ulcer

Robert Fitridge

A 68-year-old woman attends the outpatient department with an ulcer on her left leg. She tells you it has been present for 2 months. She remembers knocking her leg on the end of her bed. The ulcer on her leg has become fairly painful over the last week. She has had a similar ulcer on her leg in the past which was treated by ‘bandaging’.

Q.1

What other information would you like from the history to ascertain the cause of the ulcer?

She is not a diabetic, but does take tablets for her blood pressure. She is not sure what these are. She is on no other medications. She has had no other illnesses of note, but has had varicose veins ever since the birth of her children. On further questioning, she reveals that the left leg was very swollen for 2 or 3 months after her third pregnancy but she never had any tests to see why. This has been her ‘bad leg’ ever since. Her leg ulcer is shown in Figure 25.1.

image

Figure 25.1

Q.2

Describe what you see.

In addition to what is shown in the photograph, both legs show evidence of chronic venous insufficiency. There is loss of subcutaneous fat, and this atrophy has caused an ‘inverted champagne bottle appearance’. There is pigmentation above each ankle. There are no ulcers on the feet or toes.

Q.3

What else are you going to look for before you complete your examination of her legs?

On general examination she is mildly obese and has a blood pressure of 160/110 mmHg. The rest of the cardiorespiratory and abdominal examination is unremarkable. Her left leg shows varicosities in the distribution of the long saphenous vein. The right leg is similarly affected with varicosities and changes of chronic venous insufficiency in the lower third of the calf. You note the skin around the ulcer is mildly inflamed and tender and you think the ulcer is infected. The peripheral pulses and neurological exam of the lower limbs are normal.

Q.4

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