Foot and Leg Ulcers

Eastern Vascular Society

GOAL: To evaluate and categorize lesions of the foot and leg by etiology and severity so that appropriate treatment can be undertaken.

PERTINENT HISTORY:

1. Duration of ulcer(s)
2. Known underlying disease

• Atherosclerosis/peripheral vascular disease
• Diabetes
• Venous disease
• Collagen disease

3. History of trauma
4. Presence or absence of pain with ulcer
5. Location of ulcers

• Pretibial
• Perimalleolar
• Forefoot/digits
• Over bony prominences

PHYSICAL EXAMINATION:

1. Complete peripheral vascular examination including pulses, ankle brachial indices, estimation of pallor with elevation, capillary refill and dependent rubor. Exam should look for aneurysms, bruits and signs of cardiac disease source of proximal emboli.
2. Venous Doppler examination in appropriate cases.
3. Neurologic examination focusing on presence of neuropathy.
4. Evaluate ulcer for exposed bone or tendon, signs of granulation, signs of deep infection.
5. Note size, number and distribution of ulcers. Multiple small bilateral lesions are more common with arterities.

DIFFERENTIAL DIAGNOSIS:

1. Ischemic - from arterial occlusive disease, atheroembolization or arteritis. With occlusive disease patients usually have a history of claudication, prior surgery or other ischemic syndrome. Atheroembolic disease usually is associated with a proximal source (cardiac, aorta or peripheral arteries). Arteritides are usually associated with systemic complaints and a relatively normal vascular examination.
2. Neurotrophic Ulcers - usually are associated with systemic peripheral neuropathies from diseases such as Diabetes, Alcoholism, Thyroid Disease. There are usually physical findings of neuropathy and the lesion is usually located at a point of chronic pressure (e.g. over a bony prominence). Note: Neuropathy and ischemia can coexist. In such cases the ischemia must be evaluated and addressed.
3. Venous ulcers - are usually perimalleolar and associated with the signs and symptoms of chronic venous disease.
4. Malignancy/Infection - rarely malignancies may present as a chronic extremity ulcer or a chronic ulcer may undergo secondary malignant degeneration. Additionally, underlying invasive infection (including osteomyelitis) may exacerbate an extremity lesion and prevent ulcer healing.

DIAGNOSTIC TESTS:

1. When ischemia is considered:

1. Segmental blood pressures - If normal or non compressible use plethysmography, digital pressure or TcPO2.
2. Consider ultrasound of peripheral arteries or heart if atheroembolism suspected (i.e. distal lesion with relatively normal proximal exam).
3. Any abnormality suggestive of ischemia should be referred to a vascular surgeon. Note: Absent pulse in a diabetic with an ulcer should be referred to a surgeon.

2. Neuropathic Ulcer:

1. Rule out ischemic component (see above).
2. Rule out underlying osteomyelitis (foot x-ray/MRI as clinically indicated).
3. Culture of ulcer
4. Fasting glucose consider GTT.

3. Venous Ulcer:

1. Duplex evaluation of venous system.
2. Culture ulcer

4. Arteritis:

1. Collagen vascular screen
2. Culture ulcer