Leg Ulcer
The term ulcus cruris ( Latin ulcus "ulcer", and crus "thigh, lower leg ") or lower leg ulcer describes an ulcer in the tissue of the lower leg in medicine . The plural form Ulcera cruris denotes in addition to the general plural ( the ulcers of the thigh ) several wounds on one leg and Ulcera crurum means that there are wounds on both legs. A leg ulcer usually develops into an open, mostly exuding wound that does not heal for a long time and is therefore referred to as a " chronic wound ". This disease and its treatment were already described in the 14th and 15th centuries. Colloquially, the leg ulcer is also referred to as the "open leg" . It mostly affects older people with multiple underlying diseases ( multimorbid ).
A leg ulcer often occurs as the most severe form of chronic venous insufficiency ( venous leg ulcer ). If it shows no healing tendency within three months despite optimal therapy and does not heal within twelve months, it is considered therapy-resistant .
| Classification according to ICD-10 | |
|---|---|
| L97 | Leg ulcer, not elsewhere classified |
| I83.0 | Varices of the lower extremities with ulceration |
| I83.2 | Varices of the lower extremities with ulceration and inflammation |
| ICD-10 online (WHO version 2019) | |
definition
A leg ulcer is an atraumatic loss of tissue substance (reaching at least into the dermis ), which is typically associated with signs of inflammation. It is most often found in the area of the distal lower leg in the vicinity of the upper ankle joint ( venous leg ulcer ). This substance defect shows up clinically as an infected, often painful wound with a characteristic, very low tendency to heal .
distribution
From a leg ulcer Women are affected more often than men. Ulcus cruris rarely occurs before the age of 40 . From the age of 80, according to various studies , the frequency rises to around one to over three percent. In Germany around 80,000 people suffer from a venous leg ulcer . Around 80% to 90% of all ulcers are considered venous and around 10% are due to arterial circulatory disorders .
Causes and origins
The basic cause of all forms of leg ulcer is a reduction in the healing tendency when there is insufficient blood supply to the affected tissue ( macro and microcirculation ). The trigger is often a minor trauma (minor injury). An open ulcer is usually colonized by bacteria and thus also shows signs of inflammation in the vicinity.
(Non-inflammatory) vascular diseases (peripheral arterial occlusive disease, venous insufficiency , angiodysplasia and lymph drainage disorders) from inflammatory (accompanying vasculitis in collagenoses or the like, livedovasculitis, periarteritis nodosa, pyoderma gangrenoclastic vasculitis and cutaneous vasculitis) differentiated leukocytosum. Next, a distinction microcirculation disorders ( diabetic microangiopathy , cryoglobulinemia, Necrobiosis Lipoidica, ulcer Hypertonicum Martorell, cholesterol emboli and calciphylaxis) of hematological ( spherocytosis , thalassemia , sickle cell and sideroblastic anemia ), myeloproliferative ( polycythemia vera , thrombocythemia and Werlhof's disease ) and neuropathic causes. Also infections ( mycoses , bacteria , protozoa and viruses ), metabolic disorders ( amyloidosis , gout and diabetes mellitus ), skin tumors and lesions can lead to leg ulcers.
In the case of more frequent causes, this can also be found in the specific clinical name of a leg ulcer : venous leg ulcer (generally occurring in the context of a venous disease) with its sub-forms, the varicose leg ulcer (in the context of a varicosis ) and the post-thrombotic leg ulcer (as a symptom a post-thrombotic syndrome ), arterial leg ulcers (in the PAD ), leg ulcers traumaticum ( an accident ), leg ulcers neoplasticum ( cancer related ), leg ulcers infectiosum ( infection as the main cause). A mixed leg ulcer is a form of leg ulcer in which PAD and CVI appear equally relevant.
Side factors such as allergies to ointments or reduced blood levels of albumin , iron , folic acid , selenium , vitamin C and zinc are not the cause in most cases, but they can delay the healing process unfavorably.
Venous leg ulcer
The venous ulcer as a severe form of chronic venous insufficiency - represents (CVI stage III ° to Widmer), depending on the study, with 57 to 80% of all chronic ulcers, the most common cause not spontaneously constitute abheilender wounds.
(→ main article venous leg ulcer )
(→ For the causes and consequences of CVI in general, see its main article )
Ulcus cruris arteriosum
Arterial ulceration occurs in 4–30%, mixed arterio-venous ulceration in around 10–15% and all other forms in around 6 to 10%. A frequent contributory cause is venous congestion in the tissue, which additionally restricts arterial blood flow (congestion in the capillaries, see above). Often it is minor injuries that do not heal due to the insufficient arterial supply of the tissue, become infected and thus lead to ulcers.
Among the other forms of circulatory disorder, a chronic compartment syndrome can also be hidden as the cause of the circulatory disorder , which must be recognized as quickly as possible in order to prevent further tissue destruction.
Mixed leg ulcer
A mixed leg ulcer is an ulcer for which the causes of the venous and arterial leg ulcers are equally responsible. The patients therefore have a PAD together with a CVI .
Ulcus cruris neoplasticum
One speaks of a neoplastic leg ulcer when the "open legs" are caused by malignant growths. A distinction is also made here, for example in the case of basalioma , according to the depth of the ulcus cruris rodens (superficial) and ulcus cruris terebrans (deep).
Clinical manifestations
A leg ulcer generally appears as a substance defect of the skin and underlying tissues that is infected.
The venous leg ulcer occurs particularly frequently in the distal area of the lower leg. It can also encompass the lower leg in a circular manner.
An ulcus cruris arteriosum occurs more often on the toes, but also on the sole of the foot at the level of the heads of the metatarsal bones.
Investigation methods
Inspection and measurement of the ulcer, if possible also a photographic documentation, facilitate the later assessment of the therapeutic measures as well as the cooperation of the patient and are of forensic importance in individual cases . However, the whole body is not examined on its own, as the multiple illnesses usually present in old people mean that several factors may determine the chronicity of the event.
The aim of the measures that go beyond the clinical examination is to differentiate the corresponding underlying diseases as reliably as possible. As diagnostic methods for this purpose include the Doppler sonography of the veins and arteries, as well as in peripheral arterial disease , the angiography in use.
In addition, it may also be necessary to treat neuropathic ulcers ( malum perforans ), e.g. B. diabetes mellitus , infectious ulcers (e.g. leishmaniosis cutis , ulcus tropicum , ulcerating syphilis ), ulcerating malignant tumors (e.g. squamous cell carcinoma (also on the bottom of a leg ulcer ), basal cell carcinoma , sarcoma , malignant lymphoma ) and more rarely differentiate ulcers in haematological diseases (e.g. sickle cell anemia ).
treatment
Treatment is based on the causes. Eliminating these is often difficult. First and foremost, general measures, in particular to reduce risk factors such as reducing obesity, optimal control of any existing diabetes mellitus or increased blood pressure, are generally helpful.
Operational approach
Venous leg ulcer
In chronic compartment syndrome is a fascia - surgery ( fasciotomy and fasciectomy) followed by skin grafting carried out to the persistent and progressive tissue damage by preventing the too tight fascial sheath.
In the case of venous insufficiency of the superficial veins ( varicosis ), pressure relief in the venous system can be achieved surgically (for example by variceal stripping ). Usually this is just one of several measures required to counteract the ongoing and progressive damage to the smallest vessels that are important for microcirculation.
(→ main article varicosis )
Ulcus cruris arteriosum
The aim here is to promote blood circulation, compression therapy is contraindicated . In some cases, surgical measures can improve arterial blood flow. Suitable measures for this can be balloon dilatation or a supply with a vascular prosthesis depending on the indication .
(→ main article PAOD )
Conservative treatment
For the local treatment of a leg ulcer , the ulcer is first cleaned and then a wound pad is applied. The therapy initially focuses on supporting the formation of granulation tissue and then promoting the epithelialization leading to healing . In the meantime, the edema must be minimized, especially in the area of the wound bed, as it has a sensitive effect on the microcirculation necessary for healing.
In the case of venous leg ulcers , therapy also aims primarily to improve venous return. Compression therapy is of particular importance here . To improve venous function also is sclerotherapy used. With bandages, care must be taken that the so-called "resting pressure" is low, but that the swelling is still significantly reduced (working pressure). In the case of hand-wound bandages, short-stretch compression bandages are therefore preferable to long-stretch compression bandages.
In the case of ulcus cruris arteriosum , the focus of treatment is on improving the arterial blood flow. Compression therapy is generally contraindicated if the peripheral arterial pressure is below 80 mmHg. But even with better pressure values, compression therapy for PAOD belongs in the hands of the experienced. The assessment is particularly difficult in the case of simultaneous media sclerosis , as is practically regularly encountered in diabetes mellitus .
Treatment attempts with animal fat preparations, bath additives, enzymes, fly maggots, leeches, temporary use of hydrocolloid skin substitutes, as well as ointments and powders (the latter partly also containing antibiotics ) are undertaken. There is a high risk of allergies .
Follow-up treatment and prevention
A compression therapy with Kompressionsbandagierungen to support the work of the muscle pump and the ankle pump is used, the effectiveness of the compression effect can be increased by a high working pressure and low static pressure to ensure, through the use of pressure pads. There are also special compression stockings , so-called ulcer stocking systems, which are suitable for supplying compression with existing leg ulcers. If, on the other hand, the wound has healed and the leg has been decongested, medical compression stockings will be continued. Some models are pretreated with skin-caring ingredients or made from a silver-coated thread material that prevents the colonization of germs and odor formation.
economic aspects
Since this disease causes a high level of suffering and - in terms of treatment material alone - high costs and the population over 80 years of age will rise massively in the next 40 years , special attention must be paid to preventing this disease from a young age .
literature
- B. Kahle et al. a .: Evidence-based therapy for chronic leg ulcers . In: Dtsch Arztebl Int . No. 108 (14) , 2011, pp. 231-237 ( aerzteblatt.de ).
- Diane Quintal, Robert Jackson: Leg ulcers: A historical perspective. In: Clinical Dermatology , 8, 1990, No. 3/4, pp. 4-12.
Web links
Individual evidence
- ↑ Standards of the ICW e. V. for the diagnosis and treatment of chronic wounds . (PDF) In: Wundmanagement , Issue 2, Volume 11, mhp-Verlag 2017, pp. 81–86
- ^ Wolfgang Wegner: Master Lorenz. In: Werner E. Gerabek , Bernhard D. Haage, Gundolf Keil , Wolfgang Wegner (eds.): Enzyklopädie Medizingeschichte. De Gruyter, Berlin / New York 2005, ISBN 3-11-015714-4 , p. 964.
- ↑ Ingrid Rohland: The book of old damage. Part II: Commentary and dictionary (= Würzburg medical historical research. Volume 23). Würzburg 1982, ISBN 978-3-921456-34-7 .
- ↑ Guideline on the diagnosis and treatment of venous leg ulcers on the website of the German Society for Phlebology, accessed on January 31, 2018
- ↑ a b c d e f F. H. Mader u. a .: General medicine and practice: Instructions in diagnosis and therapy. With questions about the specialist examination. Springer, 2007, ISBN 978-3-540-71902-1 , p. 214 ( books.google.de ).
- ↑ a b J. Braun u. a .: Clinical guidelines for internal medicine. Urban & Fischer-Verlag, 2009, ISBN 978-3-437-22293-1 , p. 180 ff. ( Books.google.de ).
- ↑ a b c S3 guideline of the German Society for Phlebology for the diagnosis and therapy of venous leg ulcers, 2008, awmf.org (PDF) accessed February 19, 2016
- ↑ a b c K. Protz u. a .: Modern wound care. Urban & Fischer-Verlag, 2007, ISBN 978-3-437-27881-5 , p. 40 ff. ( Books.google.de ).
- ↑ a b c K.-H. Altenkamper u. a .: Phlebology for practice. Walter de Gruyter, 2001, ISBN 3-11-016875-8 , p. 127 ff.
- ↑ a b S. Danzer: Chronic wounds: assessment and treatment. W. Kohlhammer Verlag, 2009, ISBN 978-3-17-020669-4 , p. 19 ( books.google.de ).
- ↑ S. Massalme: Crash Course Pathology. Urban & Fischer-Verlag, 2004, ISBN 3-437-43380-6 , p. 198 ( books.google.de ).
- ↑ a b c A. Berger u. a .: Plastic surgery: basics, principles, techniques. Springer, 2002, ISBN 3-540-42591-8 , p. 64 ( books.google.de ).
- ↑ Kerstin Protz: Modern wound care. Practical knowledge, standards and documentation . 8th edition. Elsevier Verlag, Munich 2016, page 139
