Orthopedics - Extremity Ulcerations
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- 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
- 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