Nature of the wound floor Orthopedic abnormalities
The wound floor of purely venous ulcers has at the most It is important – also in regard to the effectiveness of
a coating of yellowish or whitish, fibrinous necrotic compression bandages – to check the mobility of the
slough, and the ulcer usually produces hardly any exu- large joints, taking particular care to detect incipient stiff-
date. Black necrotic tissue at the wound margins also ening of the ankle joints. Postthrombotic patients often
indicates a disorder of arterial perfusion. This is classified exhibit talipes and rarely ankyloses of the upper ankle as
as a mixed ulcer. A bloody-serous, purulent wound floor a sign of ulcer disease already existing for several years,
indicates the presence of infection. with cicatricial strictures resulting from frequent relapses.
State of peri-ulcer zone Recording of arterial status
Due to the venous and lymphatic stasis and the resulting It is also essential to establish the arterial blood flow sit-
skin alterations, patients with chronic venous insufficien- uation. Useful evidence is provided by the temperature of
cy are predestined to develop stasis dermatitis and con- the extremity (cold when arterial perfusion is reduced)
tact eczema. Stasis dermatitis, also known as varicose and palpation of the foot pulses. In patients with long-
eczema, develops on peri-ulcer skin and is not infrequent- standing diabetes, however, palpation of the foot pulses
ly encouraged by the use of greasy ointments. Contact cannot be used as a clinical criterion because consider-
eczema also develops as a reaction to sensitizing sub- able microcirculatory disorders may already be present
stances, such as topical antibiotics. due to pronounced media sclerosis despite well-filled
pulses, and the ulceration is therefore of mixed arterial
Edema formation and venous origin. Furthermore, diabetics may lack the
For more pronounced edema, comparative girth measure- typical clinical signs of intermittent claudication because
ments are indispensable to assess the effect of compres- of diabetic neuropathy. Peripheral pressure measurement
sion therapy by monitoring the reduction in edema. by Doppler ultrasound is also of little value in elucidating
Doppler ultrasonography as a
the arterial situation because excessively high pressure
painless, safe examination of the
leg veins
Symptomatology/pain values are measured as a result of the media sclerosis.
Ulcerations associated with primary varicosis usually The only technique which can provide further diagnostic
cause less severe symptoms – and in these cases the information in this situation is acral oscillography or pos-
edema is also less pronounced – than those developing sibly colour duplex sonography.
as a result of CVI of postthrombotic origin. Especially the
1) Stasis dermatitis with “blow-
small ulcers developing in the region of a capillaritis alba Recording of venous status
outs“
can cause the patient considerable difficulties and pain. It is supremely important for therapeutic purposes to
2) Contact eczema
In general, however, ulcers with arterial involvement are exactly localize the disorder of venous return within the
much more painful than purely venous ulcers. venous system. The diagnosis is based on clinical and
instrumental examinations. Doppler ultrasound especially
is now a reliable routine diagnostic procedure for precise-
ly determining the presence and extent of extrafascial
Clinical presentation and diagnosis [18.19]
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