Lower extremity ulcers (LEUs) are very common. They are divided into two groups: leg ulcers and foot ulcers, due to differences in their causes, pathogenesis, and treatment. About 70% of leg ulcers are caused by venous disease, and almost 20% are due to arterial insufficiency or mixed arteriovenous disease. Approximately 85% of foot ulcers are caused by peripheral neuropathy, often complicated by arterial disease. Risk factors for venous leg ulcers include advanced age, female sex, a family history of venous leg ulcers, Caucasian race, a history of deep vein thrombosis or phlebitis, previous leg injury, chronic leg edema, sedentary lifestyle, and prolonged standing. Risk factors for any arterial ulcer include diabetes mellitus, hypertension, hyperlipidemia, obesity, and smoking. Risk factors for foot ulcers include loss of sensation, limited joint mobility, anatomical abnormalities, diabetes mellitus, vascular disease, and repetitive local pressure increases. Pathophysiological characteristics of ulcer types
♦ Venous ulcers: When the valves in the veins of the legs are damaged or the veins are dilated, retrograde blood flow and hypertension occur. The end result is an open, draining wound with overlying slough and surrounding induration.
♦ Arterial ulcers: Arterial ulcers result from impaired tissue perfusion. In addition to intramural restriction of blood flow, extramural strangulation and mural thickening also contribute to reduced perfusion. Causes of reduced arterial blood flow include atherosclerotic peripheral vascular disease, macro- and microvascular disease due to diabetes mellitus, vasculitis, and microthrombi. Decreased perfusion of the skin and soft tissues leads to ischemia and subsequent necrosis, resulting in leg ulceration. Recurrent episodes of ischemia and reperfusion also contribute to tissue injury.
♦ Diabetic ulcers: The causes of diabetic foot ulcers are multifactorial and include arterial insufficiency and neuropathy, which predispose individuals to injury and ulcer formation. The loss of protective sensation in patients with diabetes makes them vulnerable to physical trauma; therefore, meticulous foot care and frequent foot inspection are essential. Deficient sweating and impaired foot perfusion lead to dry skin, which facilitates skin lesions from repetitive, minimal trauma. Autonomic neuropathy leads to foot deformities (e.g., Charcot foot) resulting from pressure on prominent areas of the foot. Other abnormalities related to diabetes mellitus (such as impaired white blood cell function) impair wound healing and lead to the perpetuation of ulcers and secondary infection.
♦ Pressure ulcers: Pressure ulcers are caused by constant pressure on bony prominences such as the heel and usually develop in non-ambulatory patients. Prolonged tissue compression, along with friction and shear, produces local tissue ischemia and necrosis, leading to ulcer formation. Most types of ulcers can be identified based on their appearance and location. A history should be taken focusing on coexisting medical conditions, such as diabetes mellitus, peripheral arterial disease, and deep vein thrombosis, which may provide clues to the underlying cause of the ulcer. In addition to an examination of the wound and surrounding skin, the physical examination should include a neurovascular assessment to identify neuropathy and arterial insufficiency.
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