What is a leg ulcer?
The term leg ulcers known medically a substance defect in the tissue of the distal lower leg area of an open, mostly moist wound that does not heal typically over a long time, impressed. This disease has been described very early. Colloquially the duodenal ulcers is also referred to as "open leg". It affects mostly older, affected by several underlying diseases (multimorbid) people.
Often, a duodenal ulcer occurs as a severe form of chronic venous insufficiency (venous ulcers). Shows it to be despite optimal therapy within three months, no tendency to heal and does not heal from within twelve months, it is considered to be resistant to therapy.
Leg ulcers definition
Under a leg ulcer is defined as a non-traumatic loss of tissue substance (at least until reaching the dermis), which typically associated with signs of inflammation. Most commonly it is found in the region of the distal lower leg near the ankle (venous ulcers). This substance defect presents clinically as infected, often painful wound with the characteristic, very low tendency to heal.
Dissemination
Of venous leg women are affected more often than men. Before age 40, the ulcer is hardly any leg. From the age of 80, the incidence increases according to different studies to approximately one to three percent. In Germany, around 80,000 people in venous leg ulcers. About 80% to 90% of all ulcers are considered conditionally venous and about 10% are due to arterial circulatory disorders
Leg ulcer causes and development
Principal cause ulcers in all forms of ulcer is healing reduction trend in the lack of blood flow to the affected tissue (macro- and microcirculation). Trigger is often a minor trauma (small injury). An open ulcer is colonized by bacteria and usually shows as well as in the area of inflammation.
Ursachenbezogen are (non-flammable) vascular disease (peripheral arterial Occlusive Disease, venous insufficiency, Angiodysplasia and lymphatic) of inflammation like trending (Begleitvaskulitis in connective tissue diseases or similar, Livedovaskulitis, Periarteritis nodosa, Pyoderma Gangrenosum and cutaneous leukocytoclastic Vasculitis) distinguished. Further there are micro circulation disorder (diabetic Microangiopathy, Cryoglobulinemia, Nekrobiosis lipoidica, Ulcer of hypertonicum Martorell, cholesterol embolism and Calciphylaxie) of hematological (spherocytosis, thalassemia, sickle cell and sideroblastic anemia), myeloproliferativen (Polycythaemia vera, Thrombocythemia and Morbus Werlhof) as well as neuropathic causes. Also infections (fungus, bacteria, protozoa and viruses), metabolic disorders (amyloidosis, gout and diabetes mellitus), skin tumors and injuries can the Ulcus cruris cause.
With frequent causes of these can also be found in the specific clinical description of a leg ulcer again. Leg ulcers (generally occurring in the course of venous disease) ulcers with its sub-forms, the leg ulcers Varicose (as part of a Varicosis) and the leg ulcer postthromboticum (as a symptom of post-thrombotic syndrome) of gastric arterial leg ulcers (in PAOD), leg ulcers traumaticum (an accident), venous leg neoplasticum (carcinombedingt), leg ulcers infectiosum (infection as the main cause). As venous leg mixtum is a form of leg ulcers referred to in PAOD and CVI seem equally relevant.
In addition to factors such as allergies to ointments or decreased blood levels of albumin, iron, folic acid, selenium, vitamin C and zinc, although in most cases not the cause, but may delay the progression of healing unfavorable.
Venous Leg Ulcers
Venous ulcers than most severe form of chronic venous insufficiency (CVI - Stage III ° Widmer) is, according to the study, with 57 to 80% of all chronic ulceration is the most common cause of not spontaneously abheilender wounds are.
(Main article venous ulcers)
(Too causes and consequences of CVI in general, see the main article)
Arterial leg ulcers
Arterial ulcers are caused mixed in 4-30% found arteriovenous ulcerations in about 10-15%, and all other forms in about 6 to 10%. Common causal factor is also a venous congestion in the tissues, the arterial blood supply additional limits (congestion in the capillaries so). Often there are minor injuries that do not heal due to the minor arterial supply to the tissues become infected and lead to ulcers.
Among the other forms of circulatory disorder, a chronic compartment syndrome may be hidden as a cause of circulatory disturbance, which must be recognized as soon as possible to prevent further tissue destruction.
Leg ulcer mixtum
As venous leg mixtum refers to an ulcer for which the causes of venous and arterial leg ulcers are equally responsible. In the patients so there is a PAD along with a CVI.
Leg ulcer neoplasticum
Of venous leg neoplasticum is when the "open legs" caused by malignant growths. Here, a distinction is also, for example, when basal cell carcinoma according to the depth extent of the leg ulcer ulcerating (superficial) and leg ulcers terebrans (deep).
Clinical manifestations
A leg ulcer impressed principle as substance defect of the skin and underlying tissues that is infected.
The venous leg ulcers is particularly common in the distal lower leg. It can include the lower leg also circular.
A leg ulcer Arterial often occurs in the toes, but also on the soles of the level of the heads of the metatarsals.
Research methods
Inspection and measurement of the ulcer, if possible, photographic documentation, facilitate the subsequent assessment of therapeutic measures as well as the cooperation of the patient and in individual cases of forensic importance. However, not a lower leg alone, but the whole body is investigated, as a result of most existing multiple diseases of the elderly determine the chronicity of the action may be several factors.
The aim of the clinical investigation beyond measures is to differentiate as safe as possible, the corresponding underlying diseases. As a diagnostic-relevant processes are, inter alia, the Doppler sonography of the veins and arteries, as well as in peripheral arterial occlusive disease angiography in use.
BEYOND it may also be necessary neuropathic ulcers (Mal perforant), eg diabetes mellitus, infectious ulcers (eg Leishmaniosis cutis ulcer tropicum, ulcerative syphilis), ulcerative malignant tumors (eg, squamous cell carcinoma (also on the bottom of a leg ulcer), basal cell carcinoma, sarcoma, malignant lymphoma) and more rarely ulcers in hematologic disorders (eg, sickle cell anemia ) to differentiate.
Leg ulcers treatment
The treatment is based on the causes. This is often difficult to eliminate. First and foremost are therefore in principle general measures, in particular to reduce risk factors, such as reducing obesity, optimal adjustment of any existing diabetes mellitus or increased blood pressure helpful.
Surgical Procedure
Venous Leg Ulcers
In chronic compartment syndrome, a fascial surgery (fasciotomy and fasciectomy) is performed, followed by skin grafting to prevent the continued and progressive tissue damage due to the tight fascial sheath.
With venous insufficiency of the superficial veins (varicose veins) can be achieved surgically pressure relief in the venous system (for example, by Varicectomy). This is usually only one of several necessary measures to address the ongoing and progressive damage to important microcirculation smallest vessels.
Arterial leg ulcers
Goal here is to promote blood circulation, compression therapy is contraindicated. In some cases, surgical procedures can achieve an improvement of the arterial blood flow. Appropriate measures for this purpose can be to indication a balloon or a supply by vascular prosthesis.
Conservative treatment
The local treatment of gastric ulcers runs from the principle that the ulcer is to clean first, then the formation of granulation tissue and then leading to healing epithelialization be encouraged. Meanwhile, the edema must be minimized in particular in the area of the wound as it will decrease the time required to cure microcirculation sensitive.
When venous leg ulcer therapy also aims primarily at improving venous return. Of particular importance is the compression therapy here. To improve the venous function, a sclerotherapy is used. When organizations make sure that the so-called "static pressure" is low, but the swelling is still significantly reduced (working pressure). When wound by hand associations therefore short stretch compression bandages long-stretch compression bandages are preferable.
In gastric arterial leg of treatment focuses on improving arterial blood flow. Compression therapy is to be regarded as fundamentally contraindicated if the peripheral arterial pressure below 80 mmHg. But even with better pressure values compression therapy in PAD belongs in the hands of the experienced. It is particularly difficult to assess at the same time mediasclerosis as it is practical to meet regularly in diabetes mellitus.
Frequently, treatment trials with animal fat preparations, bath additives, enzymes, maggots, leeches, temporary use of hydrocolloid skin substitutes, and made ointments and powders (the latter partly antibiotikahaltig). This is a high risk of sensitization
After treatment and prevention
Compression therapy with compression stockings and compression bandages to support the muscle-joint pump is used to ensure a high working pressure and low resting pressure, the effectiveness of the compression efficiency can be increased by the use of pressure pads. However can be affected by such therapy are also the microcirculation. This must be advised to use adequate exercise at the same time, if a compartment syndrome is removed or excluded, since each strain on your legs when walking would also heilungsverzögernd otherwise. There are also special compression stockings that are suitable with pressure 20mmHg at the ankle for the duration of compression. They are made of a silver-coated suture material that prevents bacterial colonization and odors. Through an inspection hole below the ball of the foot blood circulation can be well controlled. An alternative preventive measure is the intermittent vacuum therapy, short IVT. This will allow the use of pressure and vacuum to control venous return, stimulate the lymph flow and improve blood circulation in the periphery and muscles.