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PATIENT STORY

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A 60-year-old woman presents with a 3-month history of painful ulceration of her lower left leg. She has a history of congestive heart failure, diabetes, and has varicosities on the lower limbs.

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Her physical examination is unremarkable except for the presence of a 6-cm2 ulcer over her left medial malleolus. The ulcer is shallow, with a yellowish base and scattered islands of granulation tissue. There is a scaly brown-reddish hyperpigmentation surrounding the ulcer's borders without signs of infection. The patient's extremities are cool, with the presence of varicosities and edema of the left extremity making palpation of the dorsalis pedis pulses difficult. Figures 91-1 and 91-2 demonstrate a typical case of venous ulceration that may be misdiagnosed as cellulitis in its earliest stage prior to ulceration. Figures 91-3 and 91-4 illustrate an atypical location of a stasis ulceration that can be located on the lateral or posterior calf.

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FIGURE 91-1

Classic venous ulceration near the medial malleolus of a 60-year-old woman. Other characteristic features include an irregular margin, moist red base, and surrounding stasis hyperpigmentation. (Photograph courtesy of Thom Rooke, MD.)

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FIGURE 91-2

Another stereotypical venous stasis ulceration and surrounding hyperpigmentation within the distal medial gaiter distribution. (Photograph courtesy of Thom Rooke, MD.)

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FIGURE 91-3

Less often, stasis ulcerations may affect the lateral portion of the calf. This distribution suggests incompetence within the small saphenous vein with associated tributaries and lateral based perforating veins. (Photograph courtesy of Thom Rooke, MD.)

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FIGURE 91-4

Less often, stasis ulcerations may affect the lateral portion of the calf. This distribution suggests incompetence within the small saphenous vein with associated tributaries and lateral based perforating veins. (Photograph courtesy of Thom Rooke, MD.)

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EPIDEMIOLOGY

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  • Venous ulcers affect 500,000 to 600,000 people in the United States every year and account for 80% to 90% of all leg ulcers.1

  • Venous stasis ulcers are common in patients who have a history of leg swelling, varicose veins, or a history of blood clots in either the superficial or the deep veins of the legs.

  • Peak incidence occurs in women aged 40 to 49 years and in men aged 70 to 79 years.

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ETIOLOGY AND PATHOPHYSIOLOGY

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  • Venous ulcers are chronic nonhealing ulcers that occur in the lower extremities of patients with venous obstruction or valvular incompetence (often caused by a previous venous thrombosis).

  • Venous ulcers classically develop in regions of dependent swelling and edema.

  • Comorbidities that aggravate edema (such as heart failure, renal failure, hepatic ...

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