Assessment

The key to the management of leg ulcers is to understand their aetiology. 70% of leg ulcers are purely venous, 10%

Venous disease 70%

Arterial disease 22%

Rheumatoid disease 8.5%

Diabetes 5.5%

Venous disease 70%

Hypertension 17.3%

Burns 2.5%

Infections 1%

Haematological disease 1%

Lymphoedema 0.5%

Figure 15.20. Conditions associated with leg ulceration.

Hypertension 17.3%

Burns 2.5%

Infections 1%

Haematological disease 1%

Lymphoedema 0.5%

Tumour 0%

Figure 15.20. Conditions associated with leg ulceration.

purely arterial and 10% mixed arterial and venous. Diabetes mellitus and rheumatoid disease are important co-factors in some patients. In 10% no arterial or venous insufficiency is found on investigation and these probably represent postural problems or insufficiency in the lymphatic system; they are managed in the same way as venous ulcers (Fig. 15.20).

The appearance of the ulcer is of little value but clinical examination may reveal other signs of arterial or venous insufficiency.

The ABPI is a very useful guide with the following arbitrary cut off points (beware in diabetics):

• between 0.8 and 0.5 = 'mixed arterial/venous' ulcer,

• <0.5 = 'pure arterial' ulcer; manage as a critically ischaemic limb.

Venous duplex should be carried out to map the pattern of reflux in all patients with leg ulcers. In 60% the reflux is confined to the superficial (saphenous) veins, in 5% the deep veins alone and in 35% both deep and superficial veins are involved. In the latter group the reflux may be in all the deep venous segments or just in certain segments (segmental deep reflux).

It should be remembered that visible varicosities are only present in 40% of patients with superficial venous reflux.

1% of leg ulcers are due to a cutaneous malignancy (usually a squamous or basal cell carcinoma). Any ulcer failing to heal at 3 months or having an unusual clinical appearance should be biopsied.

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