Venous Ulcers

Diagnosis

How are leg ulcers diagnosed?

First, the patient’s medical history is evaluated. Lack of appropriate clinical assessment of patients with limb ulceration in the community has often led to long periods of ineffective and often inappropriate treatment. It is therefore advisable that diagnosis of ulcers should be based on a thorough clinical history and physical examination, as well as appropriate laboratory tests and haemodynamic assessment. This will assist identification of both the underlying cause and any associated diseases and will influence decisions about prognosis, referral, investigation and management. If the practitioner is unable to conduct a physical examination, they must refer the patient to an appropriately trained professional.

Ulcer stages
Stage I	Non-blanchable defined area of persistent erythema of intact light toned skin. In darker skin tones, the area may appear with persistent red, blue or purple hues. Observable pressure alteration of intact skin whose indicators are compared to an adjacent or opposite area on the body may include one or more of the following: Skin temperature (warmth or coolness) Tissue consistency (firm or boggy) Sensation (pain or itching)
Stage II	Partial thickness skin loss involving epidermis and/or dermis. This superficial ulcer presents clinically as an abrasion, blister or shallow crater.
Stage III	Full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. This ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.
Stage IV	Full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone or supporting structures (e.g., tendon, joint capsule).

Appearance

Typically, these lesions occur around the inner side just above the ankle, where venous pressure is greatest due to the presence of large communicating veins. The base of a venous ulcer is usually red. It may also be covered with yellow fibrous tissue or there may be a green or yellow discharge if the ulcer is infected. Fluid drainage can be significant with this type of ulcer.

The borders of a venous ulcer are usually irregularly shaped and the surrounding skin is often discoloured and swollen. It may even feel warm or hot. The skin may appear shiny and tight, depending on the amount of oedema (swelling). The skin may also have brown or purple discoloration about the lower leg, known as “stasis skin changes.”

Following may be indicative of venous disease:
Family history Varicose veins (record whether or not treated) Proven deep vein thrombosis in the affected leg Phlebitis in the affected leg	Suspected deep vein thrombosis (for example, a swollen leg after surgery, pregnancy, trauma or a period of enforced bed rest) Surgery or fractures to the leg Episodes of chest pain, haemoptysis, or history of a pulmonary embolus