Approach to Diagnosis of a Patient with a Lower Extremity Ulcer
6. OTHER IMPORTANT CONSIDERATIONS 1 Infection
Indications of infection include delayed healing, rapid wound enlargement, darker color of granulation tissue, cellulitis, increased friability and bleeding, pain, persis- tently malodorous wound even after cleansing, purulent discharge, and > 105organ- isms per gram of wound tissue. Some of these signs and symptoms may be altered in immunocompromised patients.
Biopsy or curettage of the ulcer for tissue samples for culture is preferred to tissue swab in helping to differentiate between colonization vs. infection ( > 105 organisms=gm tissue) (8,18). Bacterial culture with sensitivities may guide antibiotic therapy in cellulitis or sepsis. Systemic antibiotics should not be used as they do not improve healing time of noninfected wounds and may select for resistant microor- ganisms.
6.2. Debridement
Indications for debridement include presence of necrotic tissue in the presence of ade- quate circulation, severe infection, and deep eschar with viable tissue underneath. Dia- betic foot ulcers should be debrided of callus, down to bleeding tissue. Debridement is contraindicated in noninfected wounds and in wounds free of fibrin and foreign mat- ter. One should also be cautious with patients with poor circulation, i.e., patients with arterial disease requiring surgical evaluation, and pyoderma gangrenosum.
6.3. Laboratory Investigations
Routine bloodwork such as a complete blood count and glucose may help diagnose infection, anemia, polycythemia, and diabetes. Nutritional deficiencies may be dis- closed by obtaining serum albumin, prealbumin, vitamin A, vitamin C, iron, trans- ferrin levels, and zinc (1). Other laboratory tests to consider include, but are not limited to, erythrocyte sedimentation rate, cryoglobulins, cryofibrinogen, rheuma- toid factor, antinuclear antibodies, lupus anticoagulant, antithrombin III, protein C, protein S, hepatitis A and C antibodies, and=or hepatitis B surface antigen (8,21). If the ulcer fails to heal after 3–6 months of treatment, biopsy may help exclude mali- gnancy or vasculitis. Mycobacterial and fungal cultures should also be considered.
6.4. Noninvasive vs. Invasive Studies
Investigations begin with the physical examination of the pulses, followed by an ABPI. An ABPI should be performed by dividing the systolic pressure at the ankle (dorsalis pedis or posterior tibialis) by the higher of the systolic blood pressures of both arms. The importance of doing an ABPI is to rule out arterial disease, which is indicated by values < 0.9. It is essential to document a medical history of diabetes, as the ABPI can be inaccurate in these patients. In diabetics, the toe brachial index can give a more accurate indication of arterial status.
A duplex ultrasound of the lower extremities can diagnose venous reflux dis- ease. Noninvasive vascular studies can provide information about the superficial, communicating, and deep venous systems, as well as information about arterial sys- tems. They may measure degree of venous reflux, and provide data about the effi- ciency of the calf muscle pump. Examples of simple noninvasive tests include the color duplex ultrasound (considered the gold standard for diagnosing venous insuf- ficiency), photoplethysmography (PPG), and air plethysmography (APG). Invasive phlebography studies such as venography are generally only recommended as an investigation prior to valvular surgery (8,6).
If osteomyelitis is suspected, one should consider an x-ray, bone scan, com- puted tomography scan, gallium scan, and=or bone biopsy to confirm the diagnosis. Patients with chronic leg ulcers commonly have allergic contact dermatitis to topical creams and ointments containing antibacterial agents such as neomycin and bacitra- cin, lanolin, and preservatives such as parabens and should undergo patch testing (18).
7. CONCLUSION
Proper management of chronic lower extremity ulcers begins with the appropriate diagnosis achieved by history, physical examination, and appropriate diagnostic
tests. Once the underlying pathology has been correctly identified, treatment can be initiated. Briefly, in venous disease, the primary treatment is leg elevation and com- pression therapy (stockings, bandages, orthotics, and=or pneumatic compression) with consideration of skin substitutes or surgery for hard-to-heal ulcers. In arterial disease, the main goal of therapy is the re-establishment of an adequate arterial sup- ply. Therefore, referral should be made to a vascular surgeon for assessment and possible revascularization (13,22). Neuropathic ulcers must be aggressively debrided, infection treated, and pressure relieved (23). For ulcers, which look or behave atypi- cally, or fail to respond to treatment, alternative diagnoses should be considered.
In addition to the above, general principles should be applied. For example, constant monitoring for infection and sensitization to topical agents can help prevent complications. Consider biopsy if the ulcer fails to heal after 3–6 months of appro- priate therapy to rule out malignancy. Local wound care such as maintaining a moist wound environment, cleansing, debridement, and the selection of an appropriate dressing are important. Novel therapies including biologic skin substitutes and growth factors may be appropriate (1).
ACKNOWLEDGMENTS
I would like to acknowledge Amy Ramos, CCRC for her generous assistance in obtaining figures for this chapter.
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