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valve incompetence. Also very informative is colour which tend to be most exposed to mechanical injuries,
duplex sonography which is recommended as a supple- e.g. the anterior edge of tibia. Typical signs are black skin
mentary diagnostic procedure in suitable cases – espe- necroses, and subfascial structures such as tendons, mus-
cially for the deep communicating veins. cles and bones may be visible. In vasculitis, pea- to coin-
sized, occasionally extensive multiple ulcers are usually
Further, similarly non-invasive methods are venous occlu- present. Depending on the localization of the vasculitic
sion plethysmography (VOP), used to measure venous vascular lesions, these ulcers are superficial (superficial
outflow and venous capacity, as well as light reflection vasculitis) or have a deeper, punched-out appearance
rheography (LRR), although the evidential value of this (deep vasculitis).
technique is greatly restricted by insufficient repro-
ducibility. Macro-and microangiopathies and peripheral neuro-
pathies associated with diabetes mellitus may result in
Phlebography as an invasive imaging procedure involving angiopathic (diabetic gangrene) or neuropathic ulcers
the use of contrast media is now used with greater cau- (perforating disease). Because of their commonest local-
tion, but is still indispensable in many cases to establish ization – acral and on the sides of the feet when of
indications for surgery, especially in relapses following angiopathic etiology and on the sole of the foot under
Visualisation of the leg vein by
venous surgical interventions. the metacarpophalangeal joints when of neuropathic
phlebography
etiology – identifying these ulcers is unlikely to present
Recording of general condition any problems.
The physician should always search for signs of latent or
overt right ventricular failure. Clinical laboratory tests Hematological diseases such as sickle-cell anemia, sphe-
should include postprandial blood glucose, hemoglobin, rocytic anemia, thalassemia or essential thrombocytosis,
red blood count, erythrocyte sedimentation rate, C-reac- may be associated with an ulcer as a concomitant symp-
tive protein and, when appropriate, hematocrit. tom. Infections, such as ecthymas caused by staphylococ-
ci or erysipelas caused by streptococci are also possible
Differential diagnostic clarification
Although, as already mentioned, about 90 % of leg ulcers
are the consequence of chronic venous insufficiency, leg
1) Before an ulcer of arterial ori-
ulcers of non-venous origin must always be included in
gin develops, trophically altered
nails, mycoses, erythema, mar-
differential-diagnostic deliberations. Possible causes may
bling and loss of hair may be
include:
noticed.
2) Arterial leg ulcer on the exten-
Obstruction of larger and smaller arteries by peripheral
sor side of the lower leg with
exposed anterior tibial tendon.
arterial occlusive disease (pAOD), which can lead to arte-
rial leg ulcer or necrotising vasculitis. The localization of
arterial ulcers corresponds to the sites on the lower leg
Clinical presentation and diagnosis [20.21]
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