Hello!
Q. Today, in our OPD, a 45 year old diabetic Male, farmer by
profession presented with an ulcer on left lateral malleolus.
He had a history of edema in lower limb associated with
an itching 2 years ago. Since 6 months he got a non-healing ulcer on left
lateral malleolus.
On examination:-
Pigmentation of skin, eczema lipodermatosclerosis, atrophied
Blanche are present and dilated veins on the medial aspect of left lower
limb.
My question is how to differentiate whether the ulcer
is due to neuropathy, venous stasis or obliteration of artery.
Why do the above doubt arise?
Because venous ulcer are commonly found at the lower third
of the leg usually on the medial side and even on the foot.
Ans.
(I) to rule out neuropathy,
1. Ask whether he feel the ground and pebble while
walking barefoot
2. Test for the pain sensation, whether it is intact or not.
(II) Venous
ulcer have characteristic findings. History is utmost important. They are
shallow and flat. The edge is sloping and purple blue color.
The floor: - appears pink due to presence of granulation
tissue. If it is a chronic ulcer there is more white fibrous tissue. Most
important is A FAINT BLUE RIM of advancing epithelium may be seen at the
margin.
(III) To check for arterial obliteration
1. Feel the dorsal pedis pulsation.
2. Ask for claudication also.
Conclusion: - It was venous ulcer.
Then why did it appear on the lateral side? Remember! On
inspection dilated veins were found on the medial side.
Before answering the above question. Let us ask why is it most common on medial side?
There are more perforating veins on the medial side means more
pressure in that area. But that doesn't mean lateral side is spared .There is some rise in pressure on lateral side also. The only thing that precipitated this was “Trauma”.
Due to more itching on lateral side, he traumatised that area .It was initially
small in size, non-healing ulcer which is gradually increasing in the size.
Found this great article on the lower limb ulcers.
Take care:)
-Upasana Y.
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