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Differentiation of foot ulcers

Differentiation of foot ulcers
Characteristic Arterial ulcer* Venous ulcer Neuropathic ulcer*
Location Over toe joints, malleoli (over the bony prominence), anterior shin, base of heel, pressure points Medial and lateral malleolar area above bony prominence, posterior calf, may be large, circumferential Plantar surface of foot over metatarsal heads, heel, pressure points
Appearance Irregular margins, base dry and often pale or necrotic (brown/black fibrous tissue) Irregular margins, pink or red base that may be covered with yellow fibrinous tissue, exudate common (may be heavy); ulcers can be large, sometimes circumferential Punched out ulcer, usually superficial but sometimes deep, red base
Ulcer within callus Rare No Calloused border, ulcer can be underlying a callus
Foot temperature Warm or cool Warm Warm
Pain Yes, may be severe Yes, usually mild but may be severe No
Arterial pulses Absent Present Present or absent
Sensation Variable Present Absent tactile, pain, temperature and vibratory sensations
Foot deformities No No Often
Skin changes

Shiny, taut, loss of hair

Dependent rubor of leg and foot that becomes pale with leg elevation

Erythema, brown-blue hyperpigmentation can be spotty or diffuse: "stasis" changes; atrophie blanche (white sclerotic areas), edema; dry skin; varicose veins common; if lipodermatosclerosis is present, skin may be bound down; bilateral lower extremities often affected Waxy or shiny, loss of hair, may be taut; dry skin; may have non-pitting edema, especially on dorsal foot
Reflexes Present Present Absent
Ulcers on the foot and leg are most often due to arterial or venous disease, neuropathy, or more than one of these conditions. Although the most common causes of lower extremity ulcers are venous, arterial, and neuropathic, there are other causes (eg, vasculitis). Mixed ulcers are common (eg, arterial-venous, arterial-neuropathic), and characteristics will vary from single etiology ulcers. In particular, diabetic ulcers are often due to peripheral artery disease and neuropathic disease.
Duplex ultrasound is indicated in cases of ankle ulceration for detection of venous reflux. Deep venous insufficiency can lead to lateral or medial ulcer locations. In the absence of deep venous insufficiency, a lateral venous ulcer is most frequently associated with small saphenous vein reflux while medial ulcers are associated with greater saphenous vein reflux.
* Diabetic foot ulcers are often due to both arterial disease (involving the microcirculation as well as large vessels) and neuropathic disease.
Adapted from: Dormandy JA, Rutherford RB. Management of peripheral arterial disease (PAD). TASC Working Group. TransAtlantic Inter-Society Concensus (TASC). J Vasc Surg 2000; 31:S1.
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