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Extremity Ulceration
Diagnosis/Definition
- Any non-healing ulcer of an extremity, most commonly of the foot or distal leg.
- History of travel to areas endemic of cutaneous leishmaniasis.
Initial Diagnosis and Management
There are three primary types of ulcerations of the lower extremity that will require referral to the Vascular Surgery Service.
- Type 1: Ulceration of the distal extremity, typically the toes, due to arterial insufficiency. These can be painful and despite good local wound care fail to heal due to a lack of adequate blood supply. Treatment involves careful wound management and improvement of blood flow to the extremity, which often requires operative intervention.
- Type 2: Ulceration due to a neurotrophic ulcer in diabetics. This type is typically over bony prominences and is generally painless unless it is also infected. Treatment includes alleviation of any weight-bearing on this pressure area, controlling infection and assuring adequate blood flow.
- Type 3: Ulceration in the lower extremities is due to venous insufficiency. Management goals are proper support of the lower extremities with some type of compression dressing as well as controlling infection.
- Other kinds of ulcerations include those due to chronic infection, cancer, presence of a foreign body or various vasculitides. Treatment of these varies depending on the underlying etiology.
- All patients should have risk factor reduction and management of comorbid conditions.
- Specifically, smokers should be encouraged to quit smoking, people with elevated lipids should have this controlled and diabetics should have their disease maximally managed.
- Management of concomitant cardiac and pulmonary disease, which is often associated with extremity ulceration, should be addressed appropriately along with control of obesity.
Ongoing Management and Objectives
Allow healing of all ulcerations. – Management is tailored to the specific etiology.
Indications for Specialty Care Referral
All patients with a non-healing ulcer of the lower or upper extremity should be referred for evaluation to the Vascular Surgery Clinic.
Patients with history of leishmaniasis should be referred to Dermatology or Infectious Disease Clinic.
Criteria for Return to Primary Care
Once neurotrophic ulcers in diabetics or venous ulcers in patients with chronic venous insufficiency have undergone complete healing, they can go back for permanent follow-up with their primary care manager.
Patients that require arterial bypass to restore adequate flow to their extremity and thus allow healing of arterial ulcerations are followed lifelong in the Vascular Clinic to monitor their vascular grafts for both development of graft failure or progressive disease.
All patients should be followed by the primary care manager regarding risk factor reduction and treatment of associated comorbid factors.
