Intended for healthcare professionals

Clinical Review ABC of arterial and venous disease

Ulcerated lower limb

BMJ 2000; 320 doi: (Published 10 June 2000) Cite this as: BMJ 2000;320:1589
  1. Nick J M London,
  2. Richard Donnelly

    Ulceration of the lower limb affects 1% of the adult population and 3.6% of people older than 65 years. Leg ulcers are debilitating and painful and greatly reduce patients' quality of life. Ulcer healing has been shown to restore quality of life. Lower limb ulceration tends to be recurrent, and the total annual cost of leg ulceration to the NHS has been estimated at £400m.

    Causes of lower limb ulceration

    • Venous disease

    • Arterial disease

    • Mixed venous-arterial disease

    • Neuropathy

    • Trauma

    • Obesity or immobility

    • Vasculitis

    • Malignancy

    • Underlying osteomyelitis

    • Blood dyscrasias

    • Lymphoedema

    • Necrobiosis lipoidica diabetecorum

    • Pyoderma gangrenosum

    • Self inflicted


    Venous disease, arterial disease, and neuropathy cause over 90% of lower limb ulcers. It is useful to divide leg ulcers into those occurring in the gaiter area and those occurring in the forefoot because the aetiologies in these two sites are different. At least two aetiological factors can be identified in one third of all lower limb ulcers.

    Distribution of non-venous and venous ulcers of lower limb. The majority of venous ulcers are in the gaiter area and the majortiy of non-venous ulcers in foot

    Venous ulcers most commonly occur above the medial or lateral malleoli. Arterial ulcers often affect the toes or shin or occur over pressure points. Neuropathic ulcers tend to occur on the sole of the foot or over pressure points. Apart from necrobiosis lipoidica, diabetes is not a primary cause of ulceration but often leads to ulceration through neuropathy or ischaemia, or both. The possibility of malignancy, particularly in ulcers that fail to start healing after adequate treatment, should always be borne in mind. The commonest malignancies are basal cell carcinoma, squamous cell carcinoma, and melanoma.

    Common sites of venous, arterial, and neuropathic ulceration. Adapted from Tibbs et al

    Patients with reduced mobility or obesity may develop ulceration in the gaiter area because of venous …

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