Venous ulcer

187 Venous ulcer



Instruction


Look at this patient’s leg.



Salient features



History




• Varicose veins; ask about duration


• Past history of venous thromboembolism


• Duration of ulceration and whether this is the first episode or recurrent


• Pain (lack of pain suggests neuropathic aetiology)


• Rheumatoid arthritis (remember up to half the patients with rheumatoid arthritis have venous leg ulcers rather than the result of rheumatoid arthritis).



Examination




• Ulcer located on the medial aspect of leg (around the ankles) with pigmentation


• Surrounding dermatitis and excoriation from pruritus (stasis dermatitis)


• White atrophy with scars in the overlying skin


• The ulcer may be secondarily infected (cellulitis or thrombophlebitis)


• Look for varicose veins (Fig. 187.1)


• The range of hip, knee and ankle movement should be determined


• Sensation should be tested with a monofilament to exclude peripheral neuropathy (neuropathic arthritis or Charcot’s joints, see p. 496).


image

Fig. 187.1 Varicose veins of the leg (arrow).


(With permission from Kumar et al. 2009.)



Diagnosis


This patient has a venous ulcer (lesion) caused by varicose veins (aetiology), which has caused severe pigmentation and dermatitis around the ankles (functional status).



Advanced-level questions




What causes the surrounding pigmentation?


It results from extravasation of red blood cells and haemosiderin deposition.



What causes the white atrophy (atrophie blanche)?


It results from hyalization of skin vessels, leading to scars in the overlying skin.



What is the pathogenesis of venous ulcer?


Disturbed venous flow patterns and chronic inflammation probably underlie all the clinical manifestations of the disease.



How is the diagnosis confirmed?




• When the diagnosis is in doubt, a punch biopsy from the border (not the base) of the lesion is helpful.


• Color duplex scanning to define underlying venous abnormality: 60% of patients have normal deep veins with isolated superficial venous competence.

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Dec 4, 2016 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on Venous ulcer

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