WHAT IS AN OPEN LEG?A leg ulcer, or "ulcus cruris," is an open sore or ulcer on the lower leg. The normal skin in such a location has disappeared, leaving a usually irregularly bordered open area, often covered with a yellowish-brown coating or crust. The base may also initially be black (dead skin). During treatment, the color returns to its normal red. Healthy skin sometimes grows back from the edges, sometimes from the base. Before the open sore develops, there are usually long-term abnormalities in the surrounding area, such as fluid retention around the ankles (edema), varicose veins, and brown discoloration.HOW DOES AN OPEN LEG DEVELOP?The cause of a leg ulcer is usually a circulatory disorder. The heart pumps blood to the body's tissues via the arteries. This blood carries the oxygen and nutrients necessary for tissue growth and function. The arteries branch into increasingly smaller blood vessels. The smallest are called capillaries. These capillaries extract oxygen and nutrients from the blood and absorb them into the tissues. The capillaries then bundle together to form veins, and the blood, now depleted of oxygen and nutrients, is returned to the heart.
A leg ulcer can be caused by a disorder in the afferent, arterial system or by an abnormality in the venous system.
In the former case, there is narrowing of the arteries, so that insufficient oxygen and nutrients reach the tissues, causing them to die. This leads to very painful sores that are generally difficult to heal. These sores are usually located on the toes and feet and/or on the outside of the leg.
The most common cause of a leg ulcer is an abnormality in the venous system. This causes insufficient blood drainage, leading to blood pooling (congestion).
The veins contain valves that prevent blood from flowing back to the feet when the patient is standing upright. If these valves no longer close properly, blood easily flows back, increasing the pressure in the veins and capillaries. This stagnation in the bloodstream jeopardizes the nourishment of the tissues. The skin becomes more fragile, and a leg ulcer easily develops.
A previous blockage of the veins (thrombosis) is the main cause of the valves no longer closing properly.
A previous thrombosis need not always be noticed, however, as some venous thromboses are symptom-free.
When standing, the blood in the veins must be pumped upward against gravity. This is primarily accomplished by the calf muscles. Walking is therefore excellent, but standing or sitting for long periods is detrimental to the venous blood flow.
The described abnormalities in the venous system are usually permanent. Once the valves are damaged, they cannot be repaired. The malfunctioning of the valves in the venous system is called insufficiency (insufficient functioning). This condition is also referred to as chronic venous insufficiency (insufficient functioning of the veins). This brochure focuses primarily on these disorders of the blood vessels that drain blood.WHAT ARE THE PHENOMENA?A tired, heavy feeling in the legs is often the first sign of a vascular drainage disorder. Over the course of the day, the ankles swell due to fluid retention (edema). Over time, dilated veins and varicose veins become visible. Brown discoloration and eczema patches may develop. Subcutaneous hardening can also occur. Eventually, an ulcer develops: an open leg. The ulcer is usually not painful, but it can smell and produce a lot of fluid, making it difficult to move around freely. The open sores are usually located around or just above the inside of the ankle.HOW IS THE DIAGNOSIS MADE?The underlying vascular abnormality is determined. Feeling the pulse of the leg arteries or measuring the blood pressure in them is sufficient to rule out a supply disorder in the arterial system.
A leg ulcer based on a drainage disorder in the venous system is usually easy to recognize. Additional testing is sometimes necessary. At the beginning of treatment, or once the leg is closed, the fetal position is assessed for the benefit of surgical removal or "injection" (sclerosis) of the existing varicose veins. A Doppler (duplex) device is usually used for this.
Using a Doppler (duplex) device, the blood flow is audible and the direction of blood flow in the veins can be determined. With properly closing valves, the flow direction is only from the foot to the heart. With poorly closing valves, there is also a reverse flow direction. A Doppler instrument can be used to determine the extent of the vein damage. To determine the effect of valve damage on venous pressure—and the associated fluid content in the leg—plethymography can be performed. This determines how much blood is pumped upward by the calf muscles and how quickly the leg refills. If the valves don't close properly, the blood immediately falls downward, as it were, and the leg refills quickly.
Doppler and plethysmography are both non-invasive. This means they are performed without needles or incisions.
Additional radiographic examination is sometimes necessary. This involves injecting a contrast agent into the veins to make them visible.WHAT IS THE BEST TREATMENT?The main goal of leg ulcer treatment is to promote blood flow from the leg to the heart. This improves the nutrient supply to the lower leg and closes the ulcer. This can be achieved by applying special pressure bandages.
This treatment is usually performed on an outpatient basis, administered by both the general practitioner and the dermatologist. The bandage should exert firm pressure on the leg and is applied from the forefoot to the knee. The pressure is greatest around the ankle and gradually decreases towards the knee. This prevents blood from flowing back and pumps blood upward during calf muscle movements. Therefore, the bandage is only effective when the calf muscles are being used, so walking is essential.
The bandage material should preferably have a low stretch, as this, combined with the natural calf muscle pump, is more effective than elastic material. Furthermore, the latter should be removed at night because it becomes painful in a horizontal position. This is in contrast to low-stretch bandages, which can remain in place for up to several weeks. The total duration of the bandaging treatment varies from several weeks to many months. With proper bandaging technique, the risks are very low. Prolonged rest with the leg on a chair or in bed, as was done in the past, is not advisable because the calf muscles are not being used. Moreover, muscles and joints become stiff, and the risk of thrombosis increases. If the pain is severe, a short rest period may be advisable. Even after a transplant, in which a piece of skin from another location (usually the thigh) is transferred to the open wound, bed rest for a few days is sometimes necessary. Afterward, treatment with a pressure bandage is resumed, with the patient being encouraged to walk as much as possible.
The final step in the treatment of an open leg caused by a drainage disorder is wearing an elastic stocking. The goal is to prevent new open wounds. The stockings must be worn continuously. The elastic wears out, so the pressure becomes insufficient over time. The leg then swells, and a new open wound can develop. Therefore, stockings should be replaced every six months.
If a supply disruption due to a narrowing in one or more arteries is the cause of a non-healing leg ulcer, an attempt can be made to relieve the narrowing in the artery using a catheter (angioplasty) or to create a bypass. Angioplasty involves inserting a second, thinner catheter into the catheter, ending in a small, elongated balloon. This balloon is inflated at the site of the narrowing, stretching the artery and, as it were, spreading the fatty deposits.
Hospitalization may only be decided in exceptional circumstances. This is the case, for example, if the open leg has not healed after several months of treatment.WHAT CAN YOU STILL DO?- Exercise frequently (walking, cycling, swimming) and wear elastic stockings (even in warm weather). This is the most important rule of thumb. Stockings are often most needed on warm days.
- Avoid being overweight.
- Avoid constricting clothing such as tight pants, elastic bands, and the like.
- Wear comfortable footwear. High heels prevent the calf muscles from pumping properly.
- Elevate your legs when sitting for long periods. If necessary, the foot of the bed can also be raised slightly, provided this doesn't cause shortness of breath.
All these measures will certainly help prevent fluid retention and the heavy, tired feeling in your legs. Nevertheless, it remains possible for a leg ulcer to recur in the future. The underlying cause—the valves and veins not closing properly—cannot be remedied.WHAT ARE THE OUTLOOK?An open leg caused by a drainage disorder is generally not a life-threatening condition. It can, however, cause disability. A healed open leg can easily break again if fluid returns to the leg. Varicose vein surgery can sometimes completely restore blood drainage, while in most cases, wearing an elastic stocking prevents much of the discomfort. With a drainage disorder, the outlook is much less favorable. Healing is slow. If the blood vessel becomes further blocked, amputation of the foot or lower leg is sometimes necessary. |
