Lower Extremity Ulcerations

Warren W. McMurry, M.D., FACS

Lower Extremity Ulcerations Lower extremity ulcerations develop in tens of thousands of individuals in the US annually resulting in hundreds of thousands of lost work hours and generating millions in expenses. Many ulcers develop from underlying processes the individual has little control over. Examples include infectious etiologies, tumor processes such as skin cancers, hematologic disorders such as Sickle Cell Disease, drug reactions, some metabolic disorders such as diabetes, insect or animal bites, and some immunologic vascular disorders. Many are the result of dynamic forces at work in the vascular and lymphatic systems in the extremity, and there are mechanical and surgical options for prevention and treatment of these. Others are the result of traumatic processes that can be prevented. No matter what the cause, there are basic management concepts that can determine the outcome.

In most healthy individuals, minor ulcerations will heal/resolve with little more intervention than good hygiene. However, others will persist due to disturbances in various factors such as nutritional status, presence or absence of sensation, immune function, and/or circulatory status.

Proper nutrition is essential for wound healing. The cellular processes at work rely on adequate amounts of oxygen, vitamins, minerals, proteins, and glucose. Individuals with deficiencies in these components often require supplementation to achieve healing.

Individuals with impaired immune systems tend to have a difficult time healing lower extremity ulcerations. An intact immune system is essential for breaking down contaminants and waste products in the area and for preventing development of infection. Diabetics, malnourished persons, cancer patients, and persons on certain types of drugs such as steroids or chemotherapy are examples of these immune-compromised individuals. Diabetics must maintain good blood sugar control to facilitate wound healing. Steroid use and/or chemotherapy should be avoided or minimized. Antibiotics are often necessary in these individuals for even minor infections to facilitate healing and prevention of more serious infections.

Circulatory dynamics play a key role in ulcer healing/resolution. In a broad sense, the circulatory system can be thought of as one way in (arterial circulation) and two ways out (venous and lymphatic circulation). An intact (or mostly intact) arterial system is essential for delivery of oxygen, nutrients, and immunologicly active cells to the site of ulceration. Compromised arterial flow in and of itself can cause ulcerations and tissue loss. Surgical correction of inflow problems is often required to heal ulcerations.

Waste products from cellular turnover at the site of ulceration depend on the venous and lymphatic systems for removal. Dysfunction of either of these can result in swelling in the extremity, increased local tissue pressure, and decreased clearance of potentially toxic waste products. For lymphatic problems, there is little to offer surgically. 

These must be dealt with by leg elevation and use of external compression via support stockings, elastic wraps, or pneumatic boots. Venous problems also require use of external compression, but there are surgical treatments that may be appropriate in some circumstances. Special testing in a qualified vascular lab is necessary to make these determinations.

Special cases are those individuals who have lost sensation in their feet. Longstanding diabetics frequently develop this problem though there are several other causes. Prevention is the best treatment. They should inspect their feet on a regular basis making sure there are no foreign objects in their footwear and no wrinkles or folds in their hosiery. Severe cases should be considered for custom-made orthotic shoes to evenly distribute pressure over the bottom of the foot.

In summary, lower extremity ulcerations can be life altering. Preventive measures are important. When ulcers develop, the cause should be determined and dealt with promptly. Management strategies need to consider optimization of nutritional status, good hygiene, and minimizing immune function inhibitors. Optimization of circulation in and out of the extremity is also essential. Achieving these goals may require the assistance of a vascular surgeon, a wound care center, and/or information from a qualified vascular lab.