July 3, 2012


How are you differentiating the “big three”?


Lower extremity ulcers are often referred as the “big three”—arterial ulcers, venous ulcers, and diabetic foot ulcers. Are you able to properly identify them based on their characteristics? Sometimes, it’s a challenge to differentiate them.

  • Arterial ulcers tend occur the tips of toes, over phalangeal heads, around the lateral malleolus, on the middle portion of the tibia, and on areas subject to trauma. These ulcers are deep, pale, and often necrotic, with minimal granulation tissue. Surrounding skin commonly is pale, cool, thin, and hairless; toenails tend to be thick. Arterial ulcers tend to be dry with minimal drainage, and often are associated with significant pain. The patient usually has diminished or absent pulses.
  • Venous ulcers are located on the medial lower leg, medial malleolus, and superior to the medial malleolus. You rarely see them on the foot or above the knee. They have irregular wound margins and tend to be shallow and ruddy red, although slough may be present. Venous ulcers tend to have moderate to large drainage amounts. Although they don’t usually cause a lot of pain, patients may complain of “achy” legs. Surrounding skin is scaly and weepy, possibly with hemosiderin staining and edema. The patient usually has palpable pulses.
  • Diabetic foot ulcers arise on the plantar aspect of the foot, over metatarsal heads, and under the heel. They have even wound margins and often are deep ulcers with red or pale granular wound beds. Slough is common. Surrounding tissue is often a callus, and cellulitis is common. A low to moderate amount of drainage is present, and foot deformities are common. The patient typically has diminished or absent sensation in the foot. Due to vessel calcifications, we don’t rely on the ankle brachial index (ABI) for these patients. Instead, we use the toe brachial pressure index (TBPI).

Even though arterial, venous, and diabetic ulcers have specific characteristics, not all individual wounds follow the rules. We may see mixed ulcers types with components of both arterial and venous assessment findings. Diabetic foot ulcers may look arterial, especially when the toe is necrotic.

Do you rely just on your visual assessment of these types of ulcers, or do you use diagnostic testing to differentiate them? What diagnostics are you using? Do all of your patients with lower extremity ulcers get ABIs? Are you obtaining TBPIs on your diabetic patients?

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DISCLAIMER: All clinical recommendations are intended to assist with determining the appropriate wound therapy for the patient. Responsibility for final decisions and actions related to care of specific patients shall remain the obligation of the institution, its staff, and the patients’ attending physicians. Nothing in this information shall be deemed to constitute the providing of medical care or the diagnosis of any medical condition. Individuals should contact their healthcare providers for medical-related information.


2 thoughts on “How are you differentiating the “big three”?”

  1. Edna Alvarado says:

    I am a registered Dietitian and we have a discussion In our facility because one of our Dietitians don’t think that patients with toe amputations are at nutrition risk. How do we categorize these patients is it under chronic wounds?

  2. Nancy Morgan says:

    At nutritional risk or not at nutritional risk….that is the question…. Hmm, I think this would depend… Why was this patient amputated? From: trauma? arterial disease? Or a DFU?
    Is the Patient a fresh post op still in the hospital, or is the amputation over a year old and now only a scar remains?
    Each patient needs to be treated as an individual, obviously the patient who had his to amputated after a traumatic incident two years ago and has adequate calorie intake with good blood flow is totally different than a patient who has a metabolic disorder like diabetes or the patient with mild peripheral arterial disease who may always have impaired healing present.

    However, amputations on the foot are more likely to come from impaired sensation from neuropathy than from impaired nutrition… and just because you have had an amputation doesn’t necessarily mean you are nutritionally compromised. Each patient will really have to be assessed as an individual based on comorbidities and intake etc to see if they are still at a nutritional risk after their amputation and their individual circumstance.

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