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Leg ulcers
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In this chapter, you’ll learn:
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characteristics of venous, arterial and lymphaticulcers
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causes of leg ulcers
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assessment criteria for leg ulcers
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methods for diagnosing the ulcer type
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treatment options for leg ulcers.
A look at leg ulcers
 The vascular system is composed of arteries, veins, capillaries andlymphatics. Pressure from the beating heart carries blood away fromthe heart through the arteries into progressively smaller vessels untilthey connect with the capillaries. On the other side of the capillaries,small veins receive blood and pass it into progressively larger veinson its return trip to the heart. The lymphatic system is a separatesystem of vessels that collect waste products and deliver them to the venous system.Leg ulcers are chronic wounds that most often stem fromdisorders in the venous, arterial and lymphatic systems. Venous andarterial ulcers are most common in the lower leg while lymphaticulcers could also occur in the arms or the legs. Venous ulcersaccount for 70% to 90% of all leg ulcers (Briggs and Closs 2003).The underlying cause of the ulcer may also be due to a mixof venous and arterial disease (approximately 20%) and a smallpercentage of ulcers (approximately 5%) can have other causessuch as malignancy. Other causes may be vasculitic conditions suchas rheumatoid arthritis, blood disorders such as sickle cell disease,diseases such as pyoderma gangrenosum or even practitionerinduced wounds (iatrogenic) e.g. by applying bandages too tightly (Morison and Moffatt 2007).
 Just the facts
PVD has left ahole in my life.
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224LEG ULCERS
 Venous ulcers
 Venous ulcers, which result from venous hypertension, occur on thelower leg. They affect about 1% of the population as a whole but aremost common in older adults, affecting approximately 3.5% of thepopulation older than age 65.
 Venous anatomy and function
In the circulatory system, arteries carry blood away from the heartand veins carry blood back to the heart. Capillaries connect thesetwo systems. On the venous side, venules are the small veins thatreceive blood from the capillaries and deliver it to the larger veinsfor its return trip to the heart.
Types of veins
In the lower portion of the body, where venous ulcers develop, thereare three major types of veins: superficial veins, perforator veins anddeep veins.
Skin deep
Superficial veins (e.g. long or short saphenous veins) lie just beneaththe skin and drain into deep veins through perforator veins. Varicose veins are superficial veins that have become stretched and tortuous.
Central connectors
Perforator veins connect the superficial veins to the deep veins. Their name is derived from the fact that they perforate the deepfasciae as they connect superficial veins to the deep venous system.
U-turns
Deep veins receive venous blood from the perforator veins andreturn it to the heart. The major deep veins in the leg include theposterior tibial veins, anterior tibial veins, peroneal veins and thepopliteal veins. Each of these veins parallels a corresponding artery.(See
 Major lower limb veins 
page XX.)
 Vein walls and valves
Compared to arteries of the same size, veins have thinner wallsand wider diameters. Vein walls have three distinct layers: an inner,endothelial layer (tunica intima); a middle layer of smooth muscle(tunica media); and an outer, supportive layer (tunica adventitia).
Miles ofarteries, arterioles,capillaries, venulesand veins keepblood circulating from the heart toevery functioningcell in thebody — and back.
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Major lower limb veins
Venous ulcers most commonly occur in the lower extremities. This illustrationshows the major veins in this part of the body.
Superficialcircumflex iliac veinSuperficialepigastric veinAbdominal venacavaInferior epigastricveinExternal iliac veinFemoral veinPopliteal veinFibular veinPosterior tibial veinDeep veins of thekneeInternal iliac veinCommon iliac veinLong saphenousveinPopliteal veinShort saphenousveinLong saphenousveinSuperficial veins of the thigh and kneeDeep veins of thefootSuperficial veins of the anterior foot
VENOUS ULCERS
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