Article

ABC of arterial and venous disease - Ulcerated lower limb

University of Nottingham, UK.
BMJ Clinical Research (Impact Factor: 14.09). 07/2000; 320(7249):1589-91. DOI: 10.1136/bmj.320.7249.1589
Source: PubMed

ABSTRACT Ulceration of the lower limb affects 1% of the adult population and 3.6% of people older than 65 years. Leg ulcers are debilitating and painful and greatly reduce patients' quality of life. Ulcer healing has been shown to restore quality of life. Lower limb ulceration tends to be recurrent, and the total annual cost of leg ulceration to the NHS has been estimated at £400m.

Causes of lower limb ulceration
Venous diseaseArterial diseaseMixed venous-arterial diseaseNeuropathyTraumaObesity or immobilityVasculitisMalignancyUnderlying osteomyelitisBlood dyscrasiasLymphoedemaNecrobiosis lipoidica diabetecorumPyoderma gangrenosumSelf inflicted

Aetiology
Venous disease, arterial disease, and neuropathy cause over 90% of lower limb ulcers. It is useful to divide leg ulcers into those occurring in the gaiter area and those occurring in the forefoot because the aetiologies in these two sites are different. At least two aetiological factors can be identified in one third of all lower limb ulcers.

Distribution of non-venous and venous ulcers of lower limb. The majority of venous ulcers are in the gaiter area and the majortiy of non-venous ulcers in foot

Venous ulcers most commonly occur above the medial or lateral malleoli. Arterial ulcers often affect the toes or shin or occur over pressure points. Neuropathic ulcers tend to occur on the sole of the foot or over pressure points. Apart from necrobiosis lipoidica, diabetes is not a primary cause of ulceration but often leads to ulceration through neuropathy or ischaemia, or both. The possibility of malignancy, particularly in ulcers that fail to start healing after adequate treatment, should always be borne in mind. The commonest malignancies are basal cell carcinoma, squamous cell carcinoma, and melanoma.

Common sites of venous, arterial, and neuropathic ulceration. Adapted from Tibbs et al

Patients with reduced mobility or obesity may develop ulceration in the gaiter area because of venous …

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