Leg ulcers (chronic

‫الرحيم‬ ‫الرحمن‬ ‫هللا‬ ‫بسم‬

Leg Ulcers (Chronic)
Dr. Basim M. Zaki Salem
A. Professor
Plastic & Reconstructive Surgery

By the end of this lecture you
should know:
 Definition of an ulcer.
 Common causes of leg ulcer.
 Factors that make leg ulcer chronic.
 Clinical diagnosis.
 General management.

Structure of the skin:
 The skin is the largest
organ in the body.
 It consists of epidermis
and dermis.
 It receives its blood supply
by direct cutaneous,
fascio-cutaneous and myo-
cutaneous vessels.

Functions of the skin:
 Protection.
 Sensation.
 Temp. regulation.
 Secretion.
 Excretion.
 Metabolic.
 Endocrine.
 Immunologic.
 Cosmetic.

Definition:
 What are ulcers?
 Loss of epithelial continuity in the leg, foot (an
unfavorable anatomical site).
 Ulcers are wounds or open sores that will not heal
or keep recurring.
 The epithelium is removed by trauma, or becomes
necrotic by neoplasm or disease.

 What are the symptoms of ulcers?
 Ulcers may or may not be painful. The patient
generally has a swollen leg and may feel burning or
itching. There may also be a rash, redness, brown
discoloration or dry, scaly skin.
 Main symptoms are pain, discharge, bleeding,
regional lymphadenitis.

Why does a leg ulcer become
chronic?
 Decreased skin perfusion due to arterial occlusion,
venous congestion, pressure, or trauma and
scarring.
 Infection which increases tissue damage and
deprives local tissues of oxygen due to
consumption by the inflammatory response.

 Adherence of the base and edge to the underlying
structures that interferes with wound contraction.
 Increased activity of metaloproteinases that lead to
inactivation of wound healing growth factors and
cytokines.

Causes of leg ulcers:
 Trauma: severe (+/- fracture), or repeated.
 Infection: osteomyelitis, specific infection.
 Arterial obliteration: large a., small a.
 Venous congestion: varicose veins, DVT.
 Denervation: peripheral n., spinal cord lesions.
 Malignancy: sqamous cell ca. (Marjolin’s), basal cell ca.,
secondary skin tumors.
 Lymphedema
 Pressure ulcers

 The three most common types of chronic leg
and foot ulcers include:
 Venous statis ulcers 75%
 Arterial (ischemic ulcers) 22%
 Neurotrophic (diabetic) 5%
 Ulcers are typically defined by the
appearance of the ulcer, the ulcer location,
and the way the borders and surrounding skin
of the ulcer look.

Examination of leg ulcer:
 Site, size, shape.
 Edge, base, floor.
 Tenderness, discharge.
 Relation to underlying structures.
 Condition of adjacent tissues.
 Local arterial circulation.
 Local venous drainage.
 Local innervation.
 Regional lymph nodes.

Venous ulcer:
 Causes of venous ulcer:
1-Varicose veins.
2-Deep venous thrombosis.

Venous ulcer:
 Location: Below the knee - primarily found on the inner
part of the leg, just above the ankle. Ulcers may affect one
or both legs.
 Appearance/ Base: Red in color and may be covered with
yellow fibrous tissue. There may be a green or yellow
discharge if the ulcer is infected. Fluid drainage can be
significant.
Borders: Usually irregularly shaped. The surrounding skin
is often discolored and swollen. It may even feel warm or
hot. The skin may appear shiny and tight, depending on the
amount of edema

Features of venous ulcer:
 Dull aching, bursting pain, night cramps.
 Site: in the gaiter area, never in upper 1/3.
 Edge: sloping.
 Base: shallow, fixed to deeper tissues.
 Floor: pink, fibrotic granulation tissue.
 Hyperpigmentation, edema, eczema, V.Vs.

Diagnostic help
 Transmission of percussion wave.
 Tender fascial defects.
 Cough impulse (sapheno-femoral,
saphenopopliteal junctions).
 Torniquet and Trendlenberg tests.
 + ve Homan’s sign.
 Colored doppler US (Dupplex).
 Venography.

Venous ulcers are usually superficial
and respond to compression stocking

Ischemic ulcer:
 Causes of arterial insufficiency:
1-Large artery occlusion due to athero-sclerosis, or
embolism.
2-Small artery occlusion due to Buerger’s disease,
diabetis, embolism, injury (pressure, radiation,
electrical).
3-Vasculitis as in rheumatoid arthritis.

Ischemic (Arterial) ulcer:
 Location: On the feet - often on the heels, tips of toes,
between the toes where the toes rub against one another or
anywhere the bones may protrude and rub against bed
sheets, socks or shoes. They also occur commonly in the
nail bed if the toenail cuts into the skin or if the patient has
had recent aggressive toe nail trimming or an ingrown
toenail removed.
 Appearance Base: Has a yellow, brown, grey or black
color and usually does not bleed.

Features of ischemic ulcer:
 Painful, +/- cloudication, rest pain.
 Site: tips of the toes or pressure points.
 Edge: punched-out or sloping.
 Base: deep, adherent to deeper tissues.
 Floor: greyish slough, or pale granulation.
 Pallor or purple-blue discoloration.

 Slow capillary filling time (15-30 sec.).
 Reduced vascular (Buerger’s) angle (15-30°).
 Weak or absent arterial pulsation.
 Ankle/brachial index → normal ~ 1, rest pain ~
0.3, should be 0.5-0.7 before reconstruction.
 Doppler US → normal triphasic wave pattern,
aphasic indicates bypass surgery, should be at
least biphasic before reconstruction.
 Angiography → done in hemodynamically-stable
if vascular surgery or free-flap is indicated.

An ischemic ulcer which ended in
amputation

An ischemic ulcer healed after
revascularization

Neurotrophic ulcer:
 Causes of neurotrophic ulcer:
1-Peripheral nerve lesions: diabetes, nerve injury,
leprosy.
2-Spinal cord lesions: spina bifida, syringomyelia.

 Location: Usually located at increased pressure points on
the bottom of the feet. However, neurotrophic ulcers
related to trauma can occur anywhere on the foot.
 Appearance:
 Base: Variable, depending on the patient's circulation. It
may appear pink/red or brown/ black.
 Borders: Punched out, while the surrounding skin is often
calloused.

 Features of neurotrophic ulcer:
1-Painless, insensitive surrounding tissues.
2-Site: over pressure areas in the foot.
3-Edge: punched-out.
4-Base: deep, adherent, may reach the bone.
5-Floor: necrotic tissues.
6-Normal arterial supply, venous drainage.
7-Loss of pain, touch sensation.

Neurotrophic ulcers in a diabetic
patient

Post-traumatic neurotrophic ulcers

A neurotrophic ulcer in a case of
leprosy

Traumatic ulcer +/- osteomyelitis:
 Severe trauma to the lower limb leads to
disruption of soft tissues, muscle contusion, skin
loss, vascular injury, and bone fracture.
 Adjacent tissues are ischemic, fibrotic, and
infected by multiple resistant organisms in chronic
cases.

Features of traumatic leg ulcer:
 History of trauma, recurrence (5-10 times).
 Site: often over medial surface & chin of tibia.
 Edge: sloping.
 Base: deep, adherent to underlying bone.
 Floor: granulating, fibrotic.
 There my be exposed bone, screws & plates.
 Surrounding skin is scarred.
.

Malignant ulcer (Marjolin’s):
 Causes:
1-Chronic venous ulcer.
2-Long-standing, unstable burn scar.
3-Chronically discharging sinus.

Features of Marjolin’s ulcer:
 Early ulcer, within the chronic scar may not be
typical, growth rate is slow, the edge may be flat,
not everted.
 Late ulcer, after transgressing the boundary of the
pre-existing lesion is rapidly-growing, looks like
typical squamous cell carcinoma.
 Regional L.Ns. may be enlarged +/- distant
metastases.

Marjolin ulcer on top of chronic leg
ulcer

Marjolin ulcer on top of chronic burn
scar

How to diagnose?
 Initial Assessment
 History & Clinical examination
 Hand held Doppler
 Colour Doppler scan
 Ankle-Brachial index
 Perform X-rays, MRIs, CT scans ..

Initial investigations
 Complete blood cell count (to rule out
underlying hematologic disorders)
 ESR(which is elevated in patients with many
diseases including connective tissue
diseases and associated vasculitic ulcers,
and infectious processes),
 Fasting blood glucose.
 Serum albumin and transferrin levels are very
helpful in assessing the nutritional status in
elderly patients.

 Hand-held Doppler can assess the arterial system in the lower
extremities.
 The ankle brachial index (ABI) is determined by dividing the ankle
systolic pressure by the brachial systolic pressure obtained at the same
time. This will provide an objective estimate of arterial insufficiency,
and will help in making the decision as to whether compression
therapy is appropriate.
 Color duplex ultrasound scanning for evaluation of venous obstruction
is also used to assess the location and extent of reflux.
 Plain radiographs to rule out osteomyelitis are suggested when there is
sinus tracking or when probing to bone is possible.
 Low ABI and TcPO2 significantly increase the odds ratio of
amputation in diabetics, so it is important to evaluate underlying blood
flow characteristics and determine the need for surgical consultation..

Invasive investigations
 Venography may be performed as an investigational procedure prior to
valvular surgery.
 Lower extremities arteriography is indicated in patients with ischemic
rest pain, intolerable claudication, impending gangrene, or the presence
of non-healing ulcers of suspected arterial origin.
 Quantitative bacterial culture is specific, and should be performed once
wound infection is suspected as leg ulcers are neither sterile nor need
to be sterile to heal.
 Quantitative biopsy of the ulcer bed is the current gold standard for
assessing the quality and quantity of microbial pathogens within a
wound, biopsies containing greater than 105 organisms per gram of
tissue are considered significant, and systemic antibiotic therapy
should be considered.

General management:
 Traditional treatment:
1-Debridement to remove the necrotic tissues.
2-Dressing to drain the exudate and protect the
wound from contamination.
3-Antimicrobials
topical to control bacterial count,
systemic to treat invasive or specific infection.

Types of dressings
 Moist to moist dressings
 Hydrogels/hydrocolloids
 Alginate dressings
 Collagen wound dressings
 Debriding agents
 Antimicrobial dressings
 Composite dressings
 Synthetic skin substitutes

 Treatment of the underlying pathological
condition.
1-Chronic leg ulcer is a manifestation of an
underlying pathological condition.
2-It should be treated before making treatment of the
skin condition possible.

Venous ulcer treatment
 Compression; wearing compression stockings, multi-layer
compression wraps, or wrapping an ACE bandage or
dressing from the toes or foot to the area below the knee.
Venous ulcers are treated with compression of the leg to
minimize edema or swelling
 The type of compression treatment is based on the
characteristics of the ulcer base and amount of drainage
from the ulcer.

Arterial ulcer treatment
 Arterial ulcer treatments vary depending on the severity of
the arterial disease. Non-invasive vascular tests provide the
physician with the diagnostic tools to assess the potential
for wound healing.
 Depending on the patient's condition, the physician may
recommend invasive testing, endovascular therapy or
bypass surgery to restore circulation to the affected leg.

Neurotrophic ulcers
 Avoid pressure and weight-bearing on the affected
leg.
 Regular debridement usually necessary before a
neurotrophic ulcer can heal.
 Special shoes or orthotic devices must be worn.

Surgical management:
 Excision and closure is not appropriate because local tissue
is limited, immobile and fibrotic.
 Small (< 2 cm), superficial ulcer may heal by secondary
intension.
 Large (>2 cm), deep ulcer is covered by a graft or a flap.
 Reconstructive ladder:
- Direct closure or healing by scar formation.
- Skin graft on vascularized tissue.
- Flap (pedicled or free vasularized), for exposed bone,
cartilage, tendons, nerves, big vessels, irradiated wound.

Recent treatment modalities:
 Mechanical (Expander, VAC).
 Biological (Cultured keratinocytes, Growth
factors).

Leg ulcers (chronic

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