From: Subject: Non-healing peripheral ulcers * Information for physicians Date: Thu, 25 Sep 2003 11:17:24 +0300 MIME-Version: 1.0 Content-Type: multipart/related; boundary="----=_NextPart_000_0025_01C38356.98ACBF70"; type="text/html" X-MimeOLE: Produced By Microsoft MimeOLE V6.00.2800.1165 This is a multi-part message in MIME format. ------=_NextPart_000_0025_01C38356.98ACBF70 Content-Type: text/html; charset="Windows-1252" Content-Transfer-Encoding: quoted-printable Content-Location: http://www.veins.com/info/md-info-ulcers.htm Non-healing peripheral ulcers * Information for = physicians
Nonhealing Leg = Ulcers=20
Copyright 2001 Craig = F. Feied,=20 MD, FACEP, FAAEM=20
General=20 Approach

The initial clinical history = taken from a=20 patient with chronic nonhealing ulcers should permit the = clinician=20 to focus on a fairly small group of differential diagnoses. = A=20 thorough physical exam will sometimes be diagnostic, and = will almost=20 always narrow the choices to only a few=20 alternatives.

Directed diagnostic testing = will permit=20 confirmation of the clinical suspicion and will provide a = definitive=20 diagnosis in most cases. Virtualy every cause of lower = extremity=20 ulceration is associated with one or more risk factors for = venous=20 thrombosis, and venous congestion may trigger skin breakdown = in a=20 patient whose underlying disease is otherwise well = compensated. For=20 this reason, diagnostic screening for acute venous = thrombosis should=20 be carried out whenever a patient presents with a painful or = edematous lower extremity and a new or acutely worsening = lower=20 extremity ulceration.

Local wound care may be = initiated based=20 upon nothing more than the appearance and behaviour of the = wound,=20 but a rational and comprehensive treatment plan which = addresses the=20 underlying etiology of the wound requires a firm=20 diagnosis.

The differential diagnosis of = the=20 nonhealing ulcers is not extensive, consisting of only a few = categories of diseases.

  • Infectious = conditions=20
  • Malignancy=20
  • Large vessel arterial=20 insufficiency=20
  • Small vessel arterial=20 insufficiency=20
  • Deep venous blockage or=20 insufficiency=20
  • Superficial venous = insufficiency=20 (varicose veins)=20
  • Lymphatic = obstruction=20
  • Intrinsic circulatory = insufficiency=20 Hematologic abnormalities=20
  • Collagen vascular=20 disorders=20
  • Trophic = causes=20
  • Miscellaneous =

Virtually every cause of = nonhealing=20 ulcerations falls into one of these categories. A partial = expansion=20 of these categories to include the most common specific = causes of=20 nonhealing results in a differential list that is still=20 manageable.

Expanded differential list = for=20 nonhealing wounds

  • Infectious=20 conditions=20
  • Treponemal/spirochetic (esp. = syphilitic)=20
  • Mycobacterial (m. leprae, = lupus=20 vulgaris, atypical tb, tuberculids)=20
  • Fungal (Sporotrichosis,=20 histoplasmosis, coccidiomycosis)=20
  • Bacterial=20
  • Malignancy=20
  • Basal cell (esp in = transformation of=20 pre-existing chronic ulcer)=20
  • Squamous=20
  • Kaposi's=20
  • Lymphoma=20
  • Mycosis = fungoides=20
  • Large vessel = arterial=20 insufficiency=20
  • Arteriosclerotic (including=20 arteriosclerosis obliterans)=20
  • Traumatic=20
  • Thrombotic=20
  • Small vessel = arterial=20 insufficiency=20
  • Diabetic=20
  • Hypertensive=20
  • Thromboangiitis=20 obliterans=20
  • Raynaud's & livedo=20 reticularis=20
  • Deep venous = blockage or=20 insufficiency=20
  • Thrombotic = obstruction=20
  • Extrinsic = compression=20
  • Deep valvular insufficiency = (esp=20 postphlebitic)=20
  • Superficial venous=20 insufficiency=20
  • Saphenofemoral=20 insufficiency=20
  • Saphenopopliteal=20 insufficiency=20
  • Perforator=20 insufficiency=20
  • Lymphatic=20 obstruction=20
  • Venolymphatic disease (pure=20 overload)=20
  • Primary lymphatic = insufficiency=20 syndromes=20
  • Lymphangiosarcoma=20
  • Hematologic=20 abnormalities=20
  • Anemias (esp sickle cell=20 disease)=20
  • Polycythemias =
  • Dysproteinemias=20
  • Collagen vascular = disorders=20
  • SLE & = Scleroderma=20
  • Polyarteritis = nodosum=20
  • Wegener's=20 granulomatosis=20
  • Trophic=20 causes=20
  • Diabetic = neuropathy=20
  • Alcoholic = neuropathy=20
  • Decubitus=20
  • Bone spurs=20
  • Miscellaneous=20
  • Pyoderma = gangrenosum=20
  • Gout=20
  • Porphyria=20
  • Ergotism=20
  • Drug abuse=20
  • Radiation = necrosis=20

It is important to take a = regular and=20 organized approach to the patient with nonhealing ulcers. = One such=20 approach is outlined here.

First visit: = comprehensive clinical evaluation

  1. History=20
  2. Physical = examination=20
  3. Obtain prior records and = assemble=20 patient database=20
  4. Order routine labwork if no = recent=20 results are available
    • VDRL=20
    • CBC=20
    • SMA-20=20
    • Chest = X-ray=20
    • PPD=20
    • X-ray of the ulcer=20 base
  5. Initiate routine wound care = based upon=20 appearance of wound

Second = visit: further=20 diagnostic evaluation & testing as indicated, based on=20 comprehensive clinical evaluation

  1. Evaluate for large-vessel = arterial=20 insufficiency
    • Bidirectional CW=20 doppler=20
    • Arterial (AC) = PPG=20
    • If pulses are diminished = and above=20 tests are abnormal, then perform transcutaneous tissue=20 PO2
  2. Evaluate for small-vessel = arterial=20 insufficiency
    • Transcutaneous tissue=20 PO2=20
    • Laser = doppler=20
  3. Evaluate for venous outflow=20 obstruction
    • Pneumoplethysmography = (maximum=20 venous outflow)
  4. Evaluate for deep and = superficial=20 venous valvular insufficiency
    • Venous (DC) = photoplethysmography=20 with & without tourniquets to quantify reflux and to = assess=20 correctability=20
    • BCW doppler to identify = the level=20 and site of venous reflux
  5. Evaluate for collagen = vascular=20 disease, hematologic disorders, infections
    • FANA=20
    • RA prep=20
    • Serum = complement=20
    • Fungal or bacterial = cultures of the=20 ulcer

Further=20 Evaluation

If large-vessel arterial = disease is=20 suspected

  • Duplex ultrasound = exam=20
  • Possible = arteriography=20

If small-vessel arterial = disease is=20 suspected

  • Rheumatologic = workup=20
  • Biopsy=20
  • Consideration for hyperbaric = oxygen=20 therapy

If venous obstruction or = insufficiency=20 are suspected

  • Duplex ultrasound = exam=20

If acute deep vein = thrombosis is=20 proven

  • Hospital admission &=20 anticoagulation=20
  • Hematology = consultation=20
  • Invasive radiology = consultation=20 (consider intrathrombus delivery of lytic = agent)=20

If collagen vascular disease = or=20 arteritis are suspected

  • Rheumatologic = workup=20
  • Biopsy =

If infection is=20 suspected

  • Culture &=20 sensitivity=20
  • Quantitative tissue = bacterial=20 cultures

If poor local tissue care is = suspected

  • Social services & home = care=20 arrangements=20
  • Podiatric referral for foot=20 care

If drug abuse or factitious = ulceration=20 are suspected

  • Psychiatric=20 consultation

If hematologic abnormalities = are=20 suspected

  • Hematologic = workup=20

If chronic bony = abnormalities are=20 suspected (trophic ulcer)

  • Podiatric or orthopedic=20 referral

If the patient has=20 osteomyelitis

  • Long-term central catheter=20 placement=20
  • Home infusion nurse for=20 antibiotics=20
  • Orthopedic = consultation=20

If malignancy is=20 suspected

  • Biopsy=20
  • Referral depending upon=20 results

Therapeutic=20 management

Treatment = plan

After the initial evaluation, = the=20 diagnostic workup, and completion of all diagnostic = referrals, a=20 comprehensive treatment plan will be made. The treatment = plan will=20 include a plan for progressive local wound care as well as a = plan=20 for addressing any identifiable underlying causes which may = be=20 amenable to treatment. It is recognized that in many cases = the=20 underlying disease process may not be directly=20 treatable.

Ongoing = therapy

Routine local wound care must = be carried=20 out on a regular basis. Additional therapy, such as = antibiotic=20 therapy or hyperbaric oxygen therapy, should be added as = indicated.=20 Procedures to improve or correct an underlying problem must = be=20 undertaken whenever the underlying problem can be = identified.=20 Additional or repeated diagnostic evaluation will be carried = out as=20 needed to assess response to treatment, to evaluate a change = in the=20 patient's clinical condition, or to investigate newly = suspected=20 medical problems which are believed to cause or contribute = to a=20 failure of wound healing.

Skin = grafting

When a large wound is clean and = adequately vascularized and has developed a good bed of = granulation=20 tissue, a plastic surgery consultation is indicated in order = to=20 assess the possible value of skin grafting. This often is = not=20 necessary, but in some cases may significantly decrease time = off=20 work. =

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