VENOUS STASIS ULCERS AND NON-HEALING WOUNDS OF THE ANKLES

Venous stasis ulcers of the ankles can be a very debilitating and frustating problem for patients. Frequently, these ulcers are not diagnosed as being due to underlying venous insufficiency and varicose veins, and proper treatment is delayed.

WHAT IS A VENOUS STASIS ULCER?

A venous stasis ulcer is a wound of the lower extremity due to chronic venous insufficiency. It typically occurs around the inside area of the ankle bone. It can start off as a small pin-point hole or series of holes that rapidly coalesce and form a larger ulcer. This wounds are difficult to heal, and can be a source of great frustration and pain for patients.

WHAT CAUSES A STASIS ULCER?

These difficult to heal wounds are formed due to the inherent low oxygen level of the skin in areas of skin damaged by chronic venous insuffuciency. The skin develops a brown discoloration that can be quite striking. The structure of the skin atrophies, and becomes thin and highly pigmented. It can turn a purple color in its later stages. Continuous swelling and contracting of the skin leads to cracks in the epithelium, the top layer of the skin. These cracks can become infected or expand to develop a sore. The surrounding skin environment is low in oxygen despite good pulses in the foot due to the chronic venous stasis change and scarring. Even minor trauma such as scratching can lead to the development of ulcers. These non-healing sores can become infected, and often are sites of ingress of bacteria, leading to a skin infection known as cellulitis.

HOW ARE VENOUS STASIS ULCERS DIAGNOSED?

The physical characteristics of ankle ulcers often leads to the diagnosis by physical examination. These non-healing sores present as open wounds, sometimes with yellow debris in the ulcers, in the setting of venous stasis changes. The important points to recognize when diagnosing these sores are:

1. The presence or absence of venous stasis changes and varicose veins.
2. The signs and symptoms of infection such as cellulitis or lymphangitis (red streaks up the leg in the lymph tissue rather than a diffuse redness as in the case of cellulitis).
3. The presence or abscence of pulses on the feet. In the event there is poor blood flow down to the feet, the venous stasis ulcers become more difficult to heal.
4. Other findings such as lymphedema,the patients body weight, history of tobacco abuse, previous episodes of DVT or phlebitis.

Typical stasis ulcer.

HOW ARE VENOUS STASIS ULCERS TREATED?

The treatment of venous stasis ulcers requires control of any local infection in or around the wound, decreasing the swelling, and promoting an environment for the body to heal. If there is any evidence of an infection, oral antibiotics are indicated. The swelling can be controlled by elevation of the legs, as well as compressive dressings. Promoting local conditions that encourage wound healing might start off with application of an Unna boot dressing. This dressing of gauze impregnated with zinc oxide paste is wrapped around the leg, and then covered with a compressive ACE wrap. The dressing is left on for 2-3 days, and then changed. This technique often helps to promote healing of the ulcer. If there is poor blood flow to the leg, as evidenced by a poor pulse at the ankle, then a more aggressive approach to improving the arterial blood flow might be needed if conservative management is not successful in healing the wound. The art and science of wound healing is a very important and rapidly developing field, that has spawned numerous wound healing centers.

In the setting of varicose vein with superficial venous reflux (poorly functioning greater saphenous vein), then an endoluminal approach will help to heal up the sores. This approach, called EVLT or endovenous laser treatment of varicose veins, has essentially replaced vein stripping