Anterior Tibial Venous Ulcer

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Distribution of non-venous and venous ulcers of lower limb. The majority of venous ulcers are in the gaiter area and the majortiy of non-venous ulcers in foot

Distribution of non-venous and venous ulcers of lower limb. The majority of venous ulcers are in the gaiter area and the majortiy of non-venous ulcers in foot

Venous

Above medial malleoli

Arterial

Over toe joints Anterior shin

Above medial malleoli

Anterior Ankle Skin Ulcer

Above lateral malleoli

Arterial

Over toe joints Anterior shin

Over malleoli

Under heel

Above lateral malleoli

Neuropathic

Inner side of Over toe joints first metatarsal

Over malleoli

Under heel

Inner side of Over toe joints first metatarsal head Under heel

Over malleoli

Under metatarsal head Under heel

Over malleoli

Common sites of venous, arterial, and neuropathic ulceration. Adapted from Tibbs et al

Common sites of venous, arterial, and neuropathic ulceration. Adapted from Tibbs et al

Neuropathic Ulcer
Neuropathic ulcers on sole of foot and dorsum of toe joints

compression of the sole. Note any surrounding callus typical of neuropathic ulceration and look for tracking to affect the bones of the foot.

Investigation

Patients with foot ulceration should be referred to hospital for investigation because many will have underlying arterial ischaemia that requires prompt intervention. Diabetic patients with signs of infection should have plain radiography of the foot to look for osteomyelitis. Patients with venous ulceration should have their ankle brachial pressure index measured and can be managed either primarily in the community by trained nurses or referred to hospital for further investigation into the underlying venous abnormality.

Management

Arterial Ulcer Heels
Arterial ulcer affecting the heel and shin

The management of the more unusual causes of lower leg ulceration is based on treating the underlying disease. However, because venous disease affects up to 30% of the population, it is not uncommon for patients with, for example, rheumatoid arthritis to have lower limb ulceration caused by venous disease. Indeed, in up to half of patients with rheumatoid arthritis and leg ulcers the ulceration is due to venous disease rather than to the rheumatoid arthritis.

Venous ulceration

Debate continues not only about how venous ulcers should be treated but also where they should be treated. It has recently been suggested that patients with leg ulcers should have an initial assessment in a hospital vascular clinic, with patients who are unlikely to benefit from surgery then being cared for in the community. Although this approach has the potential for large cost savings, clinical trials are required to establish cost effectiveness. There is no evidence that any form of drug treatment improves venous ulcer healing, and antibiotics should be used only if the patient has cellulitis.

Community management

Current evidence suggests that the mainstay of the community management of venous ulceration should be graduated compression bandaging. The compression bandaging should be elastic and have multiple layers with a simple, non-adherent dressing underneath. For compression bandaging to be safely applied the ankle brachial pressure index must be at least 0.8. Nurses caring for patients with venous ulcer need to be trained to measure the ankle brachial pressure index and apply compression bandages safely. The bandages should be changed once or twice a week. The healing rate depends on the initial size of the ulcer, but 65-70% of venous ulcers heal within six months.

The skin on the lower leg should be kept moist with an emollient such as simple aqueous cream or 50:50 liquid:white paraffin, and surrounding eczema should be treated with a topical steroid. It is important to keep both the primary wound dressing and any medicaments used as "bland" as possible because many patients with venous ulcers develop a contact dermatitis to wound care products.

Hospital treatment

Patients referred to a hospital clinic will have colour duplex scanning to define the underlying venous abnormality. Recent studies have shown that about 60% of patients with venous ulcers have isolated superficial venous incompetence with normal deep veins. Evidence is mounting that patients with long saphenous or short saphenous incompetence in the presence of

Dorsal Foot Arthritis

Venous ulcers usually occur above the malleoli (left) but dorsum of the foot (right)

may affect the

Venous ulcers usually occur above the malleoli (left) but dorsum of the foot (right)

may affect the

Layer Bandages
Components of Charing Cross four layer bandaging regimen. The primary wound dressing (left) is a non-adherent dressing, over which are placed (middle; top to bottom in order of use) wool, crêpe, Elset, and Coban bandages. The bandages (right) need replacing once or twice a week

normal deep veins should have surgery to correct the venous abnormality in the leg and allow ulcer healing. Patients with refluxing deep veins do not benefit from superficial venous surgery and are best managed by compression bandaging in the community.

Prevention of recurrence

The five year recurrence rate of healed venous ulcers can be as high as 40%, and preventing recurrence is therefore very important. The rate of recurrence in patients who have had surgery to correct superficial venous incompetence has not yet been established, but it is expected to be low. In patients with healed ulcers who have not had surgery, the mainstay of preventing recurrence is graduated elastic compression hosiery. One study found that ulcers recurred in 19% of patients wearing class 2 compression hosiery and in 69% of non-compliant patients. However, elderly patients with arthritis of the knee or hip may struggle to apply class 2 compression hosiery, and class 1 hosiery is a sensible compromise. Such patients may find a hosiery applicator useful.

Arterial ulceration

For arterial ulcers to heal, the underlying arterial abnormality must be corrected. Patients therefore require colour duplex scanning of their arterial system or diagnostic arteriography to define the underlying arterial abnormality. Angioplasty is the treatment of choice because bypass grafting in patients with ulcers carries an increased risk of wound or graft infection. For patients in whom angioplasty is not possible, some form of bypass operation, preferably using the saphenous vein, should be attempted.

Neuropathic ulceration

The commonest cause of neuropathic ulceration is diabetes, and many diabetic patients with neuropathic ulceration will also have an arterial problem that requires correction. In many hospitals diabetic patients with foot ulcers are managed in specialist foot clinics run by a combination of diabetes physicians, vascular surgeons, specialist nurses, and podiatrists. The principles behind treatment are to optimise blood supply, debride callus and dead tissue, treat active infection, and protect the ulcerated area so that healing can occur. This often requires the use of a protective plaster boot with a window cut out at the site of the ulcer. Once healing has occurred, the patient is fitted with footwear designed to minimise trauma and protect bony prominences.

Key references

• Ruckley CV. Caring for patients with chronic leg ulcer. BMJ 1998;316:407-8.

• Scottish Intercollegiate Guidelines Network. The care of patients with chronic leg ulcer. SIGN 26 1998July.

• Fletcher A, Cullum N, Sheldon TA. Systematic review of compression treatment for venous leg ulcers. BMJ 1997;315:576-80.

• Scriven JM, Hartshorne T, Bell PRF, Naylor AR, London NJM. Single-visit venous ulcer assessment clinic: the first year. Br J Surg 1997;84:334-6.

• Tibbs DJ, Sabiston DC, Davies MG, Mortimer PS, Scurr JH. Varicose veins, venous disorders, and lymphatic problems in the lower limbs. Oxford: Oxford University Press, 1997.

• Ruckley CV, Fowkes FGR, Bradbury AW Venous disease. London: Springer-Verlag, 1998.

• Browse NL, Burnand KG, Irvine AT, Wilson NM. Diseases of the veins. London: Arnold, 1999.

• Task Force on Chronic Venous Disorders of the Leg. The management of chronic venous disorders of the leg. Phlebology 1999;14(suppl 1).

Classes of compression stocking: most patients can be managed with below knee class 2 stockings

Pressure at ankle

Class (mm Hg) Uses

Pressure at ankle

Class (mm Hg) Uses

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