Extremity Ulcerations

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 invasive 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 due to venous insufficiency. Management goals are proper external compression of the lower extremities with some type of compression dressing, local wound care, as well as controlling infection
• Other kinds of ulcerations include those due to chronic infection, cancer, presence of a foreign body or various vasculidities. Treatment of these varies depending on the underlying etiology.
• All patients should have risk factor reduction and management of co-morbid 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

Support 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 to the Vascular Surgery Clinic and/or Wound and Ostomy Clinic for evaluation
• 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 should be returned 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 their primary care manager for risk factor reduction and treatment of associated co-morbid factors