Presentation
Leg pain, burning leg or foot pain at rest, which is relieved by lowering the foot and made worse by elevating it.
Possible findings
- Located on the lower legs and tops of the feet or toe.
- A tendency to be painful, particularly at night.
- A symmetrical shape with well-defined borders, often described as having a ‘punched-out appearance’, smooth wound edges.
- Minimal bleeding when touched or knocked.
- Cool, pale or bluish surrounding skin that appears shiny.
- Loss of leg hair.
- Faint or absent ankle pulses.
RISK Factors
Venous insufficiency, uncontrolled blood sugar DM, improper footwear, mobility problem,
improper footwear
Differential Diagnosis
Arterial ulcer
- Pressure injury, various degrees of erythema that does not blanch (turn white) when compressed.
- Skin may be tender, itchy or swollen.
- Partial-thickness skin loss involving a break in the dermis.
- Pressure ulcers.
- Ulcers appear shiny or dry with a red-pink wound bed with serum-filled blisters.
Venous leg ulcer
- shallow and superficial irregular shaped.
- Painful, edema, phlebitis or infection usually in lower leg or ankels.
Examination and investigation
- Observation, leg examination
- Capillary refill time
- A Buerger test - this involves having the patient lie flat and raising the leg 45 degrees above horizontal for 1 minute. A positive test suggestive of arterial disease is marked by the patient’s foot turning pale when elevated and subsequently becoming bright red when lowered below the bed.
- Ankle Brachial Pressure Index (ABPI) - this is where a Doppler probe is used to measure the blood pressure in both the ankle and arm. If the ratio of these two values is < 0.9, arterial disease is likely. A value of ≤ 0.5 suggests severe disease.
- Transcutaneous oximetry — this is a measurement of the skin oxygen content around a wound. Measurements < 40 mmHg indicate vascular insufficiency and < 20 mmHg indicates severe insufficiency.
Diagnosis
Arterial ulcers are caused by arterial insufficiency; that is, inadequate delivery of oxygen and nutrient-rich blood to the tissues due to deposits of circulating lipids at the sites of damaged vessel walls as a result of the effects of smoking and high blood pressure.
Management
- Lifestyle modification
- Wound care
- Treating wound infection
- Surgical
- Safety netting – infection