Arterial leg ulcer

Published on 02/04/2015 by admin

Filed under Internal Medicine

Last modified 22/04/2025

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188 Arterial leg ulcer

Instruction

Look at this patient’s leg.

Salient features

History

• Intermittent claudication

• History of underlying cardiovascular or cerebrovascular disease

• Pain in the distal foot when the patient is supine (’rest pain’ syndrome)

• Impotence

• Absence of bleeding from the ulcer

• History of precipitating trauma or underlying deformity

• History of diabetes, chronic renal failure.

Examination

• Tender, punched-out ulcers on leg (usually away from the ankle region) (Fig. 188.1)

• The ulcer is usually in the plantar surface over the heads of first and fifth metatarsals (uncommon on the dorsum of the foot because the pressure is less sustained and perfusion is better)

• Cold atrophic skin

• Loss of hair

• Thickened nails

• Peripheral pulses are not palpable or diminished (in diabetics and in chronic renal failure the arteries may be calcified, making the results of pulse examination less reliable)

• Pallor on elevation

• Redness of foot on lowering the leg (dependent rubor)

• Sluggish filling of toe capillaries.

image

Fig. 188.1 Circumscribed necrotic arterial ulcer.

(With permission from Zipes DP et al. 2007.)

Diagnosis

This patient has an arterial ulcer (lesion) caused by vascular insufficiency, as evidenced by the absence of popliteal pulses (aetiology).

Remember: An ankle–brachial index <0.6 suggests arterial compromise.

Questions

How would you investigate such a patient?

• Radiographs may show calcification of the arteries of the leg

• Doppler ultrasonography to define the severity of arterial involvement

• Measurement of segmental limb pressures

• Pulse–volume waveform and transcutaneous oxygen are particularly useful in evaluating perfusion of the diabetic foot because they are not affected by vessel calcification

• Aortography shows narrowing and stenosis of the leg arteries.

How would you manage arterial ulcers?

• General: stop smoking; control diabetes, obesity and hypertension

• Limbs: should be kept warm (but avoid local heat)

• Feet: chiropodist and foot care, appropriate foot-wear

• Regular exercise to promote development of anastomotic collateral vessels

• Low-dose aspirin

• Surgery: balloon dilatation for local iliac or femoral stenoses, aortoiliac bypass, amputation when complicated by gangrene

• Flow-limiting arterial lesions should be evaluated and reconstructed or bypassed: prosthetic vascular grafts or autologous vein grafts may be used.

Mention other causes of leg ulcers

• Venous ulcers (Case 187)

• Neuropathic: diabetes mellitus, leprosy

• Vasculitis: rheumatoid arthritis, SLE, pyoderma gangrenosum

• Haematological disorders: sickle cell anaemia, spherocytosis

• Neoplastic: basal cell carcinoma, Kaposi’s sarcoma (Case 180)

• Trauma or artefact

• Infection: postcellulitis, fungal.

Further reading

London NJM, Donnelly R. ABC of arterial and venous disease: ulcerated lower limb. BMJ. 2000;320:1589-1591. (review)

Sumpio BE. Foot ulcers. N Engl J Med. 2000;343:787-793.

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