Canadian Medical Alliance for the Preservation of the Lower Extremity
"The life of every living creature is in its blood.”
--- Leviticus 17:11
"The blood Is the life"
-- Bram Stoker
Arterial Ulcerations are caused by diminished blood flow
in the arteries--the vessels delivering blood from the heart to
Arterial ulcers are commonly associated with atherosclerosis,
a condition in which plaque builds up within the artery and
blocks blood flow. This can result in diseased tissues nourished
by that artery, which are more susceptible to trauma, ulcerations
and death of tissue.
Smokers are the classic example of those susceptible to this condition, but a variety
of conditions--including aging, diabetes, high blood pressure, high cholesterol and
end-stage kidney disease--are associated with arterial disease.
Arterial ulcers can occur anywhere. But they are common in the toes, as they are
furthest from the heart and have the smallest vessels. The toes are also exposed to
repeated trauma with weight bearing and footwear. Arterial ulcers are also common
on the outside (lateral) portion of the foot and ankle, where there is relatively less
blood flow. And they are common where the skin lies directly over bone, with little
muscle or fat to act as a cushion. Muscle also has good blood supply compared to
tissues like tendon and bone, which assists in protecting tissue that might otherwise
have poorer blood supply.
Arterial ulcers are often quite painful. In some (diabetics and others with neuropathy, those with circulation bad enough that the nerves are not functioning), they may not be particularly painful.
And because blood flow is needed to walk, patients with arterial ulcerations may also have a diminished ability to walk more than a block or two, a condition known as claudication. In some cases the circulation can be bad enough for gangrene (a localized death of tissue) to develop. Gangrenous tissues are black in colour.
In the photo above left, we see the 2nd toe with a dusky appearance, as it begins to degenerate to gangrene. The ulcer on the top of the toe was from a modest shoe-wear trauma, but the circulation was too poor to allow healing. The darkened toe doesn't look good, of course, but note the colour and texture of the skin on the other toes and the top of the foot. Note the lack of hair. Note the small discoloration on the smaller toes. Note the abnormal nails. These are all signs of poor circulation.
In the middle photo above, the patient has already lost two toes. The second toe is obviously gangrenous. But note the smaller areas of gangrenous change on the other two toes as well, on the skin on both remaining toes nearest the gangrenous second toe. Those areas are turning gangrenous as well.
In the photo above right, the toe has ulcerated enough where bone is exposed and blackened.
Each of these cases required amputation.
Amputation is unfortunate, but it may sometimes be a good result, particularly if it prevents an infection that can claim a leg or a life. In the case below, a dislocated 2nd toe developed an ulceration with bone exposure. Removal of the toe allowed for quick, uneventful healing and long-term stability.
In the photo to the left. the dorsum (top) of the foot is ulcerated, with
gangrene extending to the connective tissues and tendons and bones of the foot.
When told he would likely lose his leg, the patient showed little concern. He had no pain, and insisted he simply had very dry skin, which he wanted to treat with a moisturizer.
The state where patients mentally separate from their physical affliction and exhibit a conspicuous lack of concern for their condition, no matter how serious, is known as "la belle indifférence” (literally beautiful indifference). This French term was coined by the psychologist Pierre Janet (1859-1947). Janet studied at the Pitié-Salpêtrière Hospital in Paris under Jean-Martin Charcot, who is discussed on our page on Charcot Neuroarthropathy.
In the photo above right, we see two ulcers on the outside of the foot. This side of the foot is a common location for arterial ulcerations, as there is no major artery on this side of the foot. The ulcers are dry, and have a poor-quality wound bed, a common presentation with poor blood supply. The patient was a smoker, and there were no pulses to the foot. But this patient, too, denied there was anything wrong with his circulation.
Arterial ulcers are difficult wounds to heal. A referral to a vascular surgeon is indicated, in hopes we may improve the circulation and the odds of healing these wounds.
In the photo above, a patient who has already lost his smallest
two toes and metatarsals now has a new ulcer on the side of the
An amputation leaving three metatarsals to bear the body's weight is relatively unstable biomechanically, and in most cases would probably be ill advised, given it is susceptible to new ulcers and infections.
However, this patient bears almost no weight, and while healing was a remarkably slow process in this case, given the lack of blood supply, this ulcer eventually closed (above right) with local wound care, and has remained closed.
Above left we see an early arterial ulceration overlying the fibula. As there is no major blood vessel here, and as the location overlies bone, this is a common location for arterial ulcerations.
Above right is a more advanced ulcer a bit higher up the same side of the leg. Note the lacking skin quality, also suggestive of poor circulation.
Above is a larger wound with gangrenous changes
extending to bone. In this case the peroneal artery
was blocked, while the other arteries to the foot and
leg were intact. The outside of the leg is a common
location for arterial ulcers.
In the case to the right, all major vessels to the leg
were blocked. This example is not on the outside
(lateral) part of the leg, as is most common, but on
the front (anterior) surface.
As is common with arterial ulcers, however, this ulcer developed in skin lying directly over bone. The ulcer was precipitated by scratching. The circulation is so poor, the body could not heal even from that minimal trauma.
Calciphylaxis (calcific uremic arteriopathy) is a rare condition is found in 1-4% of patients with end-stage renal disease (kidney failure), and is another cause of arterial ulceration. Calcification of the blood vessels in the skin and fat causes degeneration of the skin, resulting in ulcerations. The condition has a high mortality rate.
Some cases of calciphylaxis can be healed, however. The woman below lost her right leg to calciphylaxis, but her left leg healed.
Arterial ulcers present a unique challenge. Any opening to the outside world is susceptible to infection. And because of diminished blood flow, patients with arterial ulcers may have difficulty fighting off infection. Antibiotics are often less effective in these wounds, as antibiotics require blood flow to be delivered to an infected wound.
Further, even without an infection present, no wound heals without blood flow, so as you might expect, ulcers associated with poor blood flow to be slow healing. So the primary treatment involves a consult to a vascular surgeon to find a way to improve blood flow to the extremity. Perhaps an angioplasty (opening a vessel with a balloon inflated in the vessel) can be considered. Perhaps a bypass may be required. Sometimes a medication may be prescribed.
And sometimes there is not much that can be done. In these cases the choice may come down to a leg amputation, whether below the knee (below left), above the knee, or at the hip (below right).
When surgical options to improve the blood flow are not available, and amputation is deemed too risky, sometimes local wound care can be surprisingly successful, even when no major vessels exist, as small collateral vessels may provide enough blood flow to heal--similar to how traffic may flow through side streets even if the expressway is closed.
Above is an arterial lesion of over a year duration in a dialysis patient too sick to undergo a vascular
procedure. In the photo on the upper left, note the poor tissue quality at the base of the wound,
with the base of the wound a yellowish grey. Redness was present surrounding the wound from infection.
Above center, antibiotics were delivered and the wound was debrided enzymatically and protected from
all pressure with a specialized offloading dressing. The wound bed was cultivated to develop a better,
red, granular wound bed (above center) and was able to heal at 5 months (above right).
Above left is an arterial lesion in a dialysis patient. The ulcer is located on the outside portion of the heel, a difficult location in terms of both blood flow and body weight. It had been present many months. The skin and soft tissues were necrotic (dead) to bone. Treatment had consisted of dressing changes applied three times per week.
The patient's circulation was unable to be revascularized surgically, leaving the option of local wound care until infection forced our hand to amputate. Treatment included very judicious debridement, offloading and a simple non-stick dressing was initiated.
Within two months (above center), the wound had a pink, granular base, and closure was achieved at 5 months. In comparison, a wound with good circulation might be expected to heal in two months (though wouldn't have been black in the first place).
Above is a case of gangrene of parts of the first three toes.
The patient was scheduled for revascularization and amputation,
but was successfully treated without surgical intervention through local
wound care, including a change in footwear and padding to separate the toes
and offload pressure. The right photo is one year later.
Above left is a neuropathic patient with a cold, pulseless foot. He put his foot by a heater during a cold snap, resulting in gangrene of the tips of the toes. When the black skin fell off, above center, bone was exposed in the 2nd and 3rd toes.
The exposed toe bones were surgically removed, but amputation was avoided as the toes healed (above right) through local wound care and offloading. (The patient did not miss a day at work during this process.)
The take home message for arterial ulcers is that nothing heals without adequate blood supply, so a vascular consultation is of top priority. However, we still cannot ignore local wound care, offloading and infection control.
There is sometimes enough collateral blood supply (blood delivered through small vessels when the larger vessels may have blockages) that healing may occur if presented with the opportunity with good local wound care and protection from weight-bearing trauma.
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This page written by Dr. S A Schumacher
Surrey, British Columbia Canada
All clinical photographs are owned and provided by Dr. S A Schumacher. They may be reproduced for educational purposes with attribution to:
Dr. S A Schumacher, Surrey, BC Canada
and a link to this website, www.CanadianMAPLE.org.
"Not all wounds are the bleeding kind.”
-- Dean Koontz, Saint Odd