Treating Venous Stasis Ulcers In The Lower Extremity

Start Page: 68

Continuing Education Course #124 October 2004

I am very pleased to introduce the latest article, “Treating Venous Stasis Ulcers In The Lower Extremity,” in our CE series. This series, brought to you by the North American Center for Continuing Medical Education, consists of regular CE activities that qualify for one continuing education contact hour (.1 CEU). Readers will not be required to pay a processing fee for this course.

Approximately 25 percent of Americans can be affected by chronic venous insufficiency. If the disease goes untreated, it can lead to venous stais ulcers in the lower extremity. In this article, Mark Beylin, DPM, discusses the etiology of venous ulcers, what to look for in the diagnostic workup of these patients, and shares his insights on different treatment strategies one may employ to help achieve healing.

At the end of this article, you’ll find a 10-question exam. Please mark your responses on the postage-paid postcard and return it to HMP Communications. This course will be posted on Podiatry Today’s Web site ( roughly one month after the publication date. I hope this CE series contributes to your clinical skills.


Jeff A. Hall
Podiatry Today

INSTRUCTIONS: Physicians may receive one continuing education contact hour (.1 CEU) by reading the article on pg. 69 and successfully answering the questions on pg. 74. Use the postage-paid card provided to submit your answers or fax the form to NACCME at (610) 560-0502.
ACCREDITATION: The North American Center for Continuing Medical Education is approved by the Council on Podiatric Medical Education as a sponsor of continuing education in podiatric medicine.
DESIGNATION: This activity is approved for 1 continuing education contact hour or .1 CEU.
DISCLOSURE POLICY: All faculty participating in Continuing Education programs sponsored by the NACCME are expected to disclose to the audience any real or apparent conflicts of interest related to the content of their presentation.
DISCLOSURE STATEMENTS: Dr. Beylin has disclosed that he has no significant financial relationship with any organization that could be perceived as a real or apparent conflict of interest in the context of the subject of his presentation.
GRADING: Answers to the CE exam will be graded by the NACCME. Within 60 days, you will be advised that you have passed or failed the exam. A score of 70 percent or above will comprise a passing grade. A certificate will be awarded to participants who successfully complete the exam.
RELEASE DATE: October 2004.
EXPIRATION DATE: October 31, 2005.
LEARNING OBJECTIVES: At the conclusion of this activity, participants should be able to:
• demonstrate a knowledge of venous anatomy and the etiology of venous ulcers;
• discuss key clinical signs of venous stasis ulcers;
• contrast the various forms of compression therapy;
• discuss key steps to facilitating a clean wound bed with venous ulcers; and
• describe possible ancillary treatments for venous ulcers.

Sponsored by the North American Center for Continuing Medical Education.

This patient developed a large blister from chronic venous insufficiency, a condition that results in blood pooling in the venous system of the lower extremities.
Here one can see the same wound on the ankle one week after application of a Profore wrap. External compression is the hallmark of treatment for venous ulcers, according to the author.
Here is a venous stasis ulcer on the medial ankle. The ulcer developed as a result of chronic venous insufficiency and minor trauma.
As you can see, this ulceration on the medial ankle exhibits some signs of healing a week later after application of an Unna boot.
After another week, one can see the development of more granulation tissue as the treatment regimen continues for this patient.
By Mark Beylin, DPM

An early sign of longstanding venous insufficiency is edema in the ankles and legs that can lead to pain. Swelling results from the blood that has pooled in the veins due to abnormal valve function. This causes venous hypertension. As the edema and hypertension continue, the skin of the lower extremities may actually leak plasma. Eventually, the capillaries burst under the high pressure, releasing red blood cells and giving the area a typical reddish-brown discoloration. Hemosiderin and lipodermatosclerosis (indurated tissue) are common skin changes one would see in patients with venous disease.4 This skin is very vulnerable to even minor trauma as a scratch or bump can result in skin breakdown.
Several theories have been proposed in reference to the exact mechanism of venous stasis ulcer formation. Some of these theories discuss white blood cell trapping, fibrin cuff hypothesis and local tissue hypoxia.5,6

Essential Diagnostic Keys
Since many ulcers have certain characteristic and historic features, it is important to obtain a thorough patient history with a specific emphasis on detailing the duration and development of the ulcers. When asking the patient questions, one should determine the initial appearance of the ulcer, what possibly caused the ulcer, chronological steps in the ulcer’s development, and symptoms of the ulcer (if any). Clinicians should also ascertain whether the patient has attempted treatment, what medications he or she is currently taking, whether there is a history of any vascular diseases and if there is any pertinent family history.
I go through a routine physical examination on every patient. A vascular component of the examination includes documenting the status of pedal pulses, capillary refill time, temperature gradient, edema, hair distribution, varicosities, skin color and appearance, and nail condition. I follow this exam with thorough neurological and orthopedic examinations.
It is particularly important to perform a dermatological exam. One should accurately measure the ulceration, documenting its length, width and depth. Carefully examine the wound bed. Assess any present exudate for quantity and quality. Examine the borders of the wound to rule out the gross presence of an underlying skin cancer. It is important to note if the ulceration extends to deeper underlying tissues such as tendons, ligaments, capsules or bone. Carefully examine the surrounding skin.
When it comes to ulcers resulting from venous insufficiency, one will often find them in the area of medial ankle or the gaiter area (in the area of the great saphenous vein). However, clinicians may find these ulcers laterally, anteriorly and posteriorly. They are usually more superficial than ulcers of other etiologies, with sharp or slanting borders and fibrotic material at the base. One will usually see moderate to high exudate due to venous hypertension. The patient may or may not have pain. One can relieve this pain by emphasizing leg elevation.

When faced with a venous ulcer, it is crucial to determine the status of venous and arterial circulation in order to identify the primary cause of the wound. Non-invasive vascular studies such as Doppler flow studies, arteriography, venography and Doppler plethysmography offer good insight into diagnosing the ulceration. After determining the exact etiology, one can formulate an appropriate treatment plan.
In the differential diagnosis of venous ulcers, one should exclude the presence of squamous cell, basal cell cancer or vasculitis. One can rule these out with a biopsy. One should have a stronger index of suspicion of a skin cancer if the ulceration is atypical in its presentation or has been present for a long time with no response to different treatment modalities.

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