Approach to a case of Leg Ulcers clinical and treatment aspects

clinical approach

1. Clinical Approach to a Patient with Leg Ulcer

2. Vascular Anatomy

3. History Mode of onset Trauma or spontaneously Traumatic ulcers generally heal by themselves if the traumatic agent is removed Ulcer in the leg with varicose veins or vascular insufficiency Sometimes a malignant ulcer (Marjolin's) may develop on the scar of a burn Duration How long is the ulcer present there? An acute ulcer will be present for a shorter duration A chronic ulcer will remain for a long period

4. Pain Is the ulcer painful? Only those ulcers associated with Marjolin's ulcer developed in the scar of a burn Inflammation will be painful Discharge Does the ulcer discharge or not? if it discharges enquiry must be made about its nature - serum, pus or blood

5. Age Atherosclerosis is obviously a disease of old age It affects men more often than women Buerger's disease (Thromboangiitis obliterans) is commonly seen in men between 20 and 40 years of age Raynaud's disease is a disease of young women Diabetic arteriopathy is commoner in middle age

6. Local Examination INSPECTION Change in colour of limb : Marked pallor is a remarkable feature of sudden arterial obstruction as seen in case of embolism or in spasm of the arterioles in Raynaud 's disease Congestion and purple-blue cyanosed appearance are the characteristic features of severe Ischaemia and pregangrenous stage As soon as the li mb is elevated it becomes pallor

7. S igns of Ischaemia Thinning of the skin Diminished growth of hair Loss of subcutaneous fat Shininess Trophic changes in the nails which become brittle and show transverse ridges Minor ulceration in the pressure areas such as heel

8. Buergers Postural Test The patient lies on his back on the examining table. The patient is asked to rai e his legs one after the other keeping the knees straight The legs of a normal individual remain pink even if they are raised to 90°. But in case of an ischemic limb elevation to a certain degree will cause marked pallor and the veins will be empty and 'guttered ‘ The angle (between the limb and the horizontal plane) a t which such pallor appears is called 'Buerger's angle' or the 'Vascular angle’ A vascular angle of less than 30° indicates severe Ischaemia

9. Capillary refilling Test After elevating the legs, the patient is asked to sit up and hang his legs down by the side of the table. A normal leg will remain pink as it was during elevated position But an ischemic leg will first become pallor when elevated and gradually become pink in horizontal position This change of color takes place slowly and is called 'the capillary filling time’ In severe ischemia it takes about 20 to 30 seconds to become pink Then the ischemic limb again changes color and becomes purple-red quickly This is du1e to the filling of the dilated skin capillaries with deoxygenated blood

10. In established gangrene Extent and Color of the gangrenous area Type - of the gangrene shou Id be noted - whether dry i.e. the part becomes mummified or wet and putrefying as seen in diabetic gangrene Line of demarcation - is often seen between the dead gangrenous part and the normal living limb It is always advisable to observe the limb above the gangrenous area. This may be congested, edematous or pale, which indicates the possibility of later involvement of this area

11. PALPATION: Skin temperature: The temperature is best felt with the back of the fingers It is always essential to compare the two limbs and to feel the whole of the affected limb to find out the zone where the temperature changes from the normal warm temperature to cold skin of the ischemic site

12. Crossed leg test (Fuchsig's test) This is performed to detect popliteal pulsation The patient is asked to sit with the legs crossed one above the other so that the popliteal fossa of one leg will lie against the knee of the other leg The patient's attention is diverted by taking history The crossed leg will show oscillatory movements of the foot which occur synchronously with the pulse of the popliteal artery If the popliteal artery is blocked, this oscillatory movement will be absent.

13. Gangrenous area By feeling the gangrenous area one can assess the type of gangrene In case of dry gangrene the part will be hard and shriveled wet gangrene the part will be edematous with or without crepitation

14. Palpation of the blood vessels

15. Crepitus Presence of crepitus is the characteristic feature of gas gangrene. This is due to presence of gas within the muscles Limb above the gangrenous area It is always a good practice to palpate the limb above the gangrenous area as a routine Tenderness along the line of the blood vessel indicates recent thrombosis Pitting on pressure suggests oedema which may be due to inflammatory condition and thrombophlebitis

16. Varicose vein association Inspection

17. Trendelenburg’s test?

18. Testing for Perforator Incompetence

19. Investigation Duplex scanning is a combination of B mode ultrasonography and Doppler study of the imaged vessels measuring ankle brachial blood pressure index ( AbPI ) Complete hemogram Hb%, total leukocyte count (TLC), differential leukocyte count (DLC) and erythrocyte sedimentation rate (ESR) „ Blood for fasting and postprandial sugar to exclude diabetes mellitus „ Blood for lipid profile serum triglyceride, serum cholesterol including HLDL, LDL an VLDL to exclude any lipid abnormalities Blood for urea and creatinine „ Chest X-ray „ Electrocardiography (ECG)

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