Leg Ulcer

Leg Ulcer: Excerpt from Field Guide to Bedside Diagnosis

Differential Overview

❑ Venous insufficiency

❑ Arterial insufficiency

❑ Diabetes/neuropathy

❑ Decubitus ulcer

❑ Hypertension

❑ Squamous cell cancer

❑ Carbuncle

❑ Vasculitis

❑ Pyoderma gangrenosum

❑ Syphilis chancre

❑ Fistula

❑ Blood disorders

❑ Brown recluse spider bite

Diagnostic Approach

Painful necrosis in a cold foot is the result of ischemia. Painless necrosis at a pressure area (MTP heads, heels, toes) is caused by neuropathy.

Ulcerations of the fingertips can be caused by Raynaud syndrome, especially in scleroderma, and by ergots, or bleomycin.

Clinical Findings

Venous insufficiency  Varicosities, “flare sign” with a splay of venules, chronic edema, and brownish hyperpigmentation are present. Stasis ulcers occur most frequently above the medial malleolus where the vascular supply is poor. The ulcer base has granulation tissue with a yellow-green exudate.

Arterial insufficiency  The leg is pale and cool, with diminished or absent pulses, hairless atrophic skin, and dystrophic nails. Ischemic ulcers most often occur on the sides of the feet, heels, toes, and nailbeds. Claudication, or rest pain diminished by dangling the feet, is present.

Diabetes/neuropathy  Ulcers develop from the combination of peripheral neuropathy predisposing to trauma and vascular insufficiency leading to poor healing. Punched-out ulcerations on the sole of the foot are common, especially under the metatarsal heads.

Decubitus ulcer  Ulcers occur in bedridden or semiambulatory patients over bony prominences, such as the malleolus or heel.

Hypertension  A painful, blue-red plaque with a purpuric halo over the lateral malleolus progresses to an ulcer.

Squamous cell cancer  The edges of the ulcer are irregular, everted, and hard.

Carbuncle  It begins as a red pustule; then the center ulcerates, with purulent drainage.

Vasculitis  Ulcers begin as palpable purpura or hemorrhagic vesicles, which progress to painful ulcers, surrounded by livedo reticularis. The ulcers heal slowly. Usual causes include lupus with antiphospholipid syndrome, scleroderma, or cryoglobulinemia.

Pyoderma gangrenosum  A central purplish area is surrounded by an intense erythema with exquisite tenderness. When the central zone sloughs, there is an ulcer with a characteristic violet undermined edge, a ragged and heaped-up border, and surrounding halo. Inflammatory bowel disease is the underlying diagnosis in more than 50%. Other causes include chronic active hepatitis B, rheumatoid arthritis, chronic myelogenous leukemia, polycythemia vera, and myeloma.

Syphilis chancre  A chancre is painless with oval, sloping edges, and bloodstained discharge. The ulcer is painless and hard to palpation. If on the leg, it will occur on the proximal thigh from contiguous spread.

Fistula  Exuberant granulation tissue around the orifice indicates a foreign body or bone infection.

Blood disorders  Ulcers occur in sickle cell anemia, polycythemia vera, dysproteinemia, leukemia, and thalassemia.

Brown recluse spider bite  A bite develops a necrotic center and then ulcerates.

Pictures

Book Source Details

• Book Title: Field Guide to Bedside Diagnosis
• Author(s): David S. Smith
• Year of Publication: 2007
• Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2007 Lippincott Williams & Wilkins.

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• Back to disease: Ulcer: Introduction
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: Field Guide to Bedside Diagnosis Authors: David S. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-78178-165-5

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