Hypertonic leg ulcer L98.4

Martorell, 1945; Hines and Farber, 1946

Usually sudden, unilateral or bilateral (50% of patients are affected bilaterally), rapidly progressive, circumscribed, ischemic, 2.0-5.0 cm large, highly painful leg ulcer, usually localized in the distal, latero-dorsal parts of the lower leg. Often a banal everyday trauma is given as the initial trigger. The main symptom is the sudden, almost unbearable, ischaemic infarction pain.

The aetiological assessment of Martorell's ulcers has been revised by several publications to the effect that, in addition to hypertension, subcutaneous arteriolosclerosis (in targeted deep biopsies a high percentage of calcifying arteriosclerosis can be detected in serial sections) is of decisive importance. Frequently (in about 60% of patients) diabetes mellitus can also be detected.

Women are preferentially affected (m:w = 4:6); in larger studein the mean age was 72 years.

Outside of the lower legs, symmetrically over the ankles or Achilles heel.

Sudden, circumscribed, highly painful, polycyclic, sharply margined ulcer with bluish-livid or black-fringed edges, which developed from a black-necrotic precursor. Most patients have a marked, usually treatment-requiring, long-term hypertension, often combined with type 2 diabetes (>50% of patients). Subtle arteriosclerosis screening can detect peripheral AVK in > 50% of patients.

Unobtrusive

In sufficiently deep excisional biopsy from the edge of the ulcer and with subtle serial histology, stenotic arteriosclerotic, sometimes calcified changes in the subcutaneous arterioles can be detected in 3/4 of the patients.

The vast majority of patients have underlying peripheral arterial occlusive disease. Therefore, in order to check the indication for vascular intervention or vascular reconstruction, the ankle arm index should be determined by Doppler sonography and blood pressure measurement and, if necessary, arterial digital subtraction angiography should be performed.

Venous leg ulcer.

Treatment of high blood pressure, pain therapy.

Surgical debridement usually leads to a rapid improvement of the very severe pain. Sufficiently deep excision, skin necroses are excised down to the fascia of the lower leg, followed by vacuum therapy for 6-10 days.

Frequent need for antibiotics postoperatively (caution: laboratory inflammation values are not conclusive: CRP is usually already elevated due to the existing ulcer; if necessary, decide according to clinical criteria).

+ if necessary split skin transplantations

Not infrequently, several follow-up surgical interventions are necessary until the wounds have healed completely.

1. Hafner J et al (2010) Martorell hypertensive ischemic leg ulcer. Arch Dermatol 146: 961-968
2. Hines E, Farber E (1946) Ulcer of the leg due to arteriolosclerosis and ischemia occurring in the presence of hypertensive disease (hypertensive-ischemic ulcers): A preliminary report. Mayo Clin 21: 337-346
3. Martorell F (1945) Las ulceras supramaleolares por arteriolitis de las grandes hipertensas. Actas Reuniones Cientificas Cuerpo Facultativo Instituto Policlinico Barcelona 1: 6