Arterial ulcers are almost always located in the lower extremities; because of the increased distance blood must travel to reach those areas. Arterial-insufficiency ulcers are commonly located on the toes, either dorsally or distally. Trauma is a leading precipitating factor in arterial- ulcer development, so potential causes of trauma should be assessed for ulcers located in unusual positions.
Arterial ulcers generally begin as small, shallow wounds that gradually increase in size and depth. Ulcers are normally round and regular in appearance, or conform to precipitating trauma. Granulation tissue, if present, is pale or gray because of decreased oxygen supply. Necrotic tissue is generally desiccated, black eschar, but may be yellow if the wound is bandaged in a way that maintains tissue hydration. Gangrene may be present with more- advanced disease. Because of diminished circulation, there is minimal or no wound drainage, even in the presence of infection, and only minimal bleeding with wound debridement.
Patients with chronic arterial-insufficiency ulcers usually show signs of decreased perfusion. When blood supply distal to the occlusion becomes inadequate, many changes occur. The epidermis becomes thinner, shiny, and dry, and there is loss of hair growth. Poor tissue oxygenation increases the risk of fungal infections, making nails yellow, thickened, and brittle. Prolonged, severe ischemia may cause muscle atrophy. Color changes may be evident, with the affected limb appearing pale, dusky, or cyanotic in color, especially with elevation. The limb may have dependent rubor. Edema is unusual with arterial insufficiency, but if present, may represent concomitant venous insufficiency or congestive heart failure. Patients with arterial insufficiency may try to reduce ischemic pain with prolonged dependent positioning, which can result in minimal edema or exacerbate co-existing venous insufficiency.
Pulses at the dorsalis pedis artery, and the posterior tibial artery, are likely decreased or absent in the case of lower- extremity arterial insufficiency. In severe cases, popliteal artery and femoral artery pulses may also be altered. If pulses are not readily palpable, more- sensitive measures of circulation testing such as a Doppler ultrasound, ABI, or toe pressure measurements should be performed.
Ischemic digits or limbs will be cool or cold to the touch because of decreased blood supply. Since the dorsum of the hand is more sensitive to temperature changes than the fingertips, skin surface temperature can easily be assessed by lightly palpating with the back of the hand, after allowing the patient to rest supine with shoes and socks removed for at least 5 minutes prior to testing. The temperature of the patient’s foot should be compared with more- proximal body areas.
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