Persistent ischemia of a limb is associated with ischemic ulceration and gangrene. Ulceration is almost inevitable once skin has thickened and the circulation is compromised. Ulceration related to arterial insufficiency occurs as a result of trauma to the toes and heel. These ulcers are painful, have discrete edges that produce a ''punched-out'' appearance, and are often covered with crust. When infected, the tissue is erythematous.

In contrast to arterial insufficiency ulceration, venous insufficiency leads to stasis ulceration, which is painless and occurs in the ankle area or lower leg just above the medial malle-olus. The classic manifestation is a diffusely reddened, thickened area over the medial malleolus. The skin has a cobblestone appearance resulting from fibrosis and venous stasis. Ulceration occurs with the slightest trauma. Rapidly developing ulcers are commonly caused by arterial insufficiency, whereas slowly developing ulceration is usually the result of venous insufficiency. Figures 15-1 and 15-2 show stasis dermatitis and ulcerations over the medial malleoli. Patients with leg ulcers should be asked the following:

''What did the ulcer look like when it first appeared?'' ''What do you think started the ulcer?'' ''How quickly did it develop?'' ''How painful is the ulcer?''

''What kind of medications have you been taking?''

''Is there a history of any generalized diseases, such as anemia? rheumatoid arthritis?'' ''Is there a family history of leg ulcers?''

Figure 15-1 Stasis dermatitis and bilateral ulceration over the medial malleoli.

Figure 15-1 Stasis dermatitis and bilateral ulceration over the medial malleoli.

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