Br. J. Surg. 1986, Vol.

73, September,
693496 Leg ulcers: epidemiology and
aetiology

I n a regional Health District with a population of 198 900,357 patients

with 424 ulcerated legs were documented, an overall prevalence of
0.18 per cent. The prevalence of ulceration in the 92 100 aged > 40 years
was 0.38 per cent. Fifty per cent of the lesions had been present for more
than one year, and 6 2 per cent of patients had never attended any hospital.
The patients were stratified by history of peripheral arterial disease. A
random sample (100 patients, 193 legs) was examined by ultrasound and
photoplethysmography to assess the venous and arterial circulation:
38per cent had evidence of deep vein involvement and 43per cent had
superficial vein incompetence. An ischaemic element was present either in
Julia V. Cornwall, isolation (9 per cent) or combined with venous disease (22 per cent) in a
Caroline J. Dore and total of 31 per cent, with a mean pressure index of 0.62 (s.d.0.14).Simple
J. D. Lewis objective methods of assessment together with dedicated community staff
Northwick Park Hospital, Watford with ready access to specialized facilities can enhance the service provided
Road, Harrow, Middlesex to patients with leg ulcers.
Correspondence to: Mr J. D. Lewis Keywords: Leg ulcers, vascular disease, varicose veins

'Ulcers on the leg form a very extensive and important class of
disease.. . the treatment of such cases is generally looked upon as
an inferior branch of practice; an unpleasant and inglorious task
where much labour must be bestowed and little honour gained.'
These words, quoted by Loudon, were first published in 1805l.
We set out to determine the prevalence of leg ulceration in a
defined health district with a population of approximately
200000. The initial survey took 3 months and was used as a
sampling frame; a random sample of 100 patients was selected
for non-invasive studies using ultrasound and photoplethysmo-
graphy (PPG)to assess arterial and venous circulation within
the limbs. Analysis of the data has allowed rationalization of
aetiological classification and subsequently of therapy.
Patients and methods
Epidemiological survey
A proforma for data on social, clinical and management aspects of leg
ulcers was circulated to all general practitioners, wards, nursing homes,
old peoples' homes and residential homes within the District. This task
was performed by one individual (J.V.C.) who contacted every G P and
district nurse within the Health District, and followed up each contact
with several personal visits. All patients with limb ulceration were
included, and every attempt made to make the initial survey
comprehensive. All subjects had ulceration of the leg; patients were not
included with isolated ulceration of the foot or toes. Data collection was
carried out between November 1981 and January 1982. In the ensuing
months 11 ulcers were referred which had been present during the study
period and these were included.
Non-invasive study
The 357 patients were stratified by history of lower limb peripheral
arterial disease (suggestive of pre-existing intermittent claudication).
Using this group as a sampling frame, 150 were selected at random and
requested to undergo a non-invasive study; 100 agreed. Most of the
investigations were undertaken in the patient's home using portable
instruments.
Arterial circulation was assessed by ankle pressure measurement
using continuous wave ultrasound'. The results were recorded as a
resting pressure index (RPI). The presence of significant atheromatous
disease as demonstrated by angiography without specific occlusion was
associated in previous studies with a pressure index of 0.878, s.d. 0.143- '.
We found that the maximum difference between the cumulative
relative frequency distributions for those with and without a previous
history of intermittent claudication occurs for an RPI of 09. Those with
an index of <0.9 were therefore considered to have significant arterial
disease and comprise the ischaemic group.
Ultrasound was used to evaluate the valvular status of deep and
superficial veins at three defined sites; the long and short saphenous
veins at their origins, and the deep popliteal vein behind the knee. A
probe was placed over the appropriate vein, localized either directly or
by reference to the associated artery and the presence or absence of reflux
recorded following calf compression6-'. As an aid in distinguishing
superficial from deep incompetence at popliteal level a calf tourniquet
was used. PPG was used to measure venous refilling time using a
modification of the technique described by Abranovitz et aL9 and
subsequently by Miles and Nicolaides". Modification was required as
frequent ankle deformity prevented significant ankle movements in this
joint. The patients were seated with both feet resting on the floor. A
transducer was attached to the skin with double sided Sellotape, either
50mm (2in.) above the medial malleolus or at the upper margin of the
ulcer. The calf was squeezed vigorously five times and the refilling time
was recorded. In the presence of an abnormal result (< 18 s) the study
was repeated after the application of a calf, and subsequently a thigh,
tourniquet. A 25 mm pneumatic cuff was used in both positions and the
pressures chosen to occlude the superficial veins only but not the deep
veins as shown by previous venographic studies". Five readings were
made for each section of this study. Deep vein damage with popliteal
incompetence was defined as a failure to convert refilling time (PPG)
with either calf or thigh tourniquet, associated with reflux uncontrolled
by calf tourniquet, recognized by the operator using continuous wave
ultrasound. Superficial vein incompetence was defined as reflux
occurring in the long or short saphenous veins recognized using
continuous wave ultrasound or by the ability to convert the refilling time
to normal with either a thigh or a calf CUKThe limitations of these
definitions will be discussed further but they were felt to be adequate for
a large scale survey.
Post-rationalization survey
Throughout this study treatment has been modified on the basis of the
objective findings and very considerable expertise in assessment and
management acquired by the nurserechnician. A further survey was
therefore undertaken 18 months after the original and was conducted in
a similar fashion during the 3 months May to July 1983. As in the first
study seven ulcers which were referred subsequently, but which were
present during this period, were included.

0007-1323/86/0!406934$3.00 0 1986 Butterworth & Co (Publishers) Ltd 693

Leg ulcers: J. V. Cornwall et al.
Statistical methods
x2 tests wereused to cornparecharacteristics of those whoconsented and
those who refused to participate in the non-invasive studies and to relate
ischaemia with history of intermittent claudication in the affected limb.
A sign test was used to compare the paired arterial ultrasound index
of the affected and non-affected limbs. McNemar's test was used to
compare the paired data on venous status.
Results
Epidemiological survey
We recorded 357 patients with 424 ulcerated legs in a population
of 198 900; 69 per cent of the patients were women. The overall
prevalence was thus 0.18 per cent. Only seven patients were
under the age of 40 years. The prevalence of ulceration in the
92 100 aged over 40 years was 0.38 per cent.
The age distribution of patients with leg ulcers is shown in
Figure I and emphasizes the marked increase that occurs with
age, particularly in the last two decades. The percentage of the
population in Harrow over the age of 65 years is 16.3 per cent
(OPCS, revised estimates 1981). This compares with a mean of
13.9percent in the North West Thames Region, and of
14.9 per cent in the outer London Boroughs.
History and treatment
Of the lesions 50 per cent had been present for > 1 year, and
some for considerably longer. A further 10 per cent had been
present for > 6 months. Of the patients 62 per cent had never
been referred to a hospital and after initial visual or verbal
diagnosis by the GP were subsequently managed by the district
nurse. There were 90 different topical agents recorded, used in
108 different ways, applied either directly onto the ulcer, the
surrounding skin, or both. Of the women 75 per cent had been
pregnant and 36 percent of the total group had had previous
major surgery (many being orthopaedic procedures). Only
8 per cent had a history suggestive of deep vein thrombosis,
19 per cent had symptoms suggestive of intermittent
claudication, 32 per cent gave a history of some form of arthritis.
As a result of the exclusion criteria only 5 per cent were diabetic.
Information was also collected on the social status of this
group of patients; 14per cent were receiving help from Social
22 1
" 41-50 51-60 61-70 71-80 > 8 0
Age (years)
Figure 1 Age distribution of patients with leg ulcers per 1000 head of
population
694
nI I
401
n
Normal Superficial Deep vein Deep and
vein defect vein defect superficial
vein defeci
Venous status
Figure 2 Percentage distribution of ischaemic limbs in relation to venous
function. c],ischaemia; 0, no ischaernia; 117 ulcerated limbs
Services o r from voluntary organizations. Only 9 per cent were
known t o require the help of a district nurse other than with their
ulcer dressings. Five per cent were completely immobile;
47 per cent never took a bath, usually due t o the fallacious belief
that their ulcer should remain dry. Many of the elderly patients
had unsatisfactory livingconditions, and some 5 per cent lived in
what can only be described as squalor.
The majority of ulcers were considered to be venous by those
providing treatment. Despite this, scant attention was paid to the
amount of compression applied to the limb; 17 per cent wore no
support at all, 51 per cent wore a single layer of bandage, of
varying length and quality, 18 per cent wore support stockings
and all of these patients attended our own outpatient
department.
Ulcers were dressed at home in 69 per cent of cases,
48 per cent by the district nurse and 21 per cent by the patient or
a relative, usually with inadequate instruction and supervision.
Nine per cent of the ulcers were dressed in GPs' surgeries. The
remaining 22 per cent were resident either in hospital or in long-
stay accomodation although not necessarily solely for the
treatment of their ulcers. In many instances the treatment in
these institutions was no more appropriate.
Non-invasive study
We examined 100 patients (193 legs) by ultrasound and PPG.
There were 117 legs with active ulceration and both legs were
examined. The venous and arterial status of the ulcerated limbs
is shown in Figure 2. Of the 117 limbs 38 per cent had popliteal
valve incompetence of which 11 per cent had a superficial
component. Forty-three per cent had superficial vein
incompetence. Ischaemia was present in 31 per cent with a mean
pressure index of 0.62 (s.d. = 0.14). In 10 per cent of the limbs no
venous o r arterial abnormality was detected in any of the
studies.
It is apparent from Figure 2 that ischaemiaeither in isolation
or combined with a venous defect is a frequent abnormality. A
history suggestive of intermittent claudication was recorded in
25 per cent of those studied non-invasively (25.6 per cent of the
affected limbs) compared with 19.6 per cent of the total
epidemiological survey. Ischaemia was present in 70 per cent of
limbs with a history of intermittent claudication, and in
17 per cent of limbs with n o such history (P<OGOl, Table 1).
Forty-two per cent of the limbs with ischaemia, however, had no
such history.
The proportion of ulcerated limbs with ischaemia in each
group is shown in Table 2. There was no ischaemia in patients
under 60 years of age. The proportion of limbs with ischaemia
increased with age (test for linear trend in proportions x: =9.3,
P = 0.002) and rose to 50 per cent in patients > 80 years of age.
Br. J. Surg., Vol. 73, No. 9, September 1986
 Leg ulcers: J. V. Cornwall et al.

Table 1 History of intermittent claudication and arterialfunctionfor 1I7 old, and we therefore considered the at risk population to be
ulcerated limbs those over 40 years. In each subsequent decade there is a
progressive increase in patients with active leg ulcers both in
History of intermittent claudication
absolute terms and relative to the population in that decade
Yes No Total (Figure I). Approximately 70 per cent of the patients with ulcers
were > 70 years old, and it is this group who have the highest
Ischaemia level of mixed venous and ischaemic disease, and would appear
Yes 21 15 36 to have least access to specialized diagnosis and treatment.
No 9 72 81 The frequent lack of any clinical assessment of patients with
Total 30 87 117 limb ulceration in the community has led to long periods of
ineffective and often inappropriate treatment. This not only
applies in terms of compression, and the inappropriate
Table 2 7he relationship of ischaemic limbs to the age of the patient application of topical agents, but also in the delay in instituting
potentially pain relieving limb salvage procedures. The concept
Age group of a panacea for limb ulcer management would no longer seem
to be tenable. Aside from the pain and frequent iatrogenic
<60 61-70 71-80 380 Total dermal problems induced, it only perpetuates the misery and
lack of reward in treatment expressed nearly 200 years ago.
No ischaemia The objective techniques chosen for further investigation,
n 11 18 31 21 81
Percentage of ultrasound and PPG, were found to be satisfactory in
age group 100.0 69.2 81.6 50.0 community use. The correlation in gross results between the two
Ischaemia procedures with regard to the venous studies means that user
n 0 8 7 21 36 preference, the need or otherwise for hard copy, and the ease
Percentage of with which both arterial and venous information can be
age group 0.0 30.8 18.4 50.0 obtained with ultrasound should be considered if choice is an
Total 11 26 38 42 117 important factor. The results of the venous studies re-
emphasize the importance of superficial vein incompetence
alone as an important aetiological factor in limb ulceration’ 5*16.
There was no significant difference in any major variable We recognize that, using these particular techniques, a
between those who consented to further study and those who percentage of patients categorized as having superficial vein
refused. The variables considered were age, sex, outpatient incompetence may have obstructed deep veins in the thigh or
referral, support stockings, history of previous ulcers, varicose calf without popliteal vein incompetence”. It is recognized that
veins, deep vein thrombosis, diabetes, arthritis, major surgery, all current methods of venous assessment are inadequate in
pregnancy and mobility. functional terms. Patients referred for further treatment without
The affected and non-affected limbs were compared in the 76 clear-cut evidence of superficial vein or perforator problems,
patients without bilateral ulceration or amputation. The RPI both clinically and objectively, should be subjected to invasive
was greater in the affected than the non-affected limb for seven investigation.
patients, and significantly worse (P =0.014) in the affected limb The recognition of the high prevalence of associated
for 21 patients. ischaemic disease is one of the most interesting findings. Careful
There was either deep or superficial vein involvement in 61 of statistical appraisal does not support the concept that patients
the affected limbs and in 45 of the non-affected limbs, a consenting t o further study were significantly different in any
significant difference (P=0.003). There were 16 patients for major characteristic to their counterparts. The proportion of
whom, as a result of immobility, there was some missing venous patients with an ischaemic element was similar in those studied
information. In the remaining 101 affected limbs there were six from the community to those previously referred to outpatients.
legs for which the assessments disagreed. O n five occasions the Continuous monitoring of all community and hospital referrals
P P G was abnormal and venous ultrasannd normal, four of these in the 2 years following the study has confirmed the presence of
legs also having an abnormal pressure index. an ischaemic element in approximately one-third of patients,
and is the only objective finding in about 10 per cent.
Postrationalization survey The diagnosis of arterial disease involving the lower limb,
We documented 210 patients representing a reduction of based on history and clinical information, is not in general a
41 per cent. major problem. However, in this particular group of patients it
presents very definite difficulties. They are frequently elderly, are
relatively or absolutely immobile, have indurated swollen limbs,
Discussion and additional associated functional abnormalities.
Anning” in 1954 analysed 1026 cases with ulcers in Leeds; 738 The relatively poor correlation between history of
were post-thrombotic, 110 varicose, and 115 associated with intermittent claudication and abnormal RPI we believe is
venous insufficiency of doubtful cause. Dale et al. (1983)13 explained on this basis. In such a group of patients the diagnosis
estimated that one in every hundred of the adult population in of arterial disease based on palpation is liable to be even more
Scotland is affected by leg ulceration. In the Basel I1 436 unreliable than normal“.
persons were screened for evidence of venous, peripheral arterial The presence of ischaemia (RPI <0.9) would appear to
and coronary heart disease. Leg ulcers (Grade 111 of their considerably prolong healing using standard techniques of
chronic venous insufficiency group) were, or had been present, in compression and forms the subject of a further study. A greater
1.3 per cent of the study group (1.1 per cent men and 1.4 per cent impact on clinical management appears to become more
women). Age was shown t o be the most important risk factor, apparent when the pressure index is less than 0.75. We are left in
chronic venous hypertension being seven times more prevalent little doubt that in practical terms its recognition is important
in those aged 60 years than in the 20 year old subjects. This and that it requires objective methods of assessment for its
present study has attempted to identify all the active leg ulcers in accurate detection.
a defined population during the period of data collection. It is The precise definition on an objective basis of the aetiological
clear that the magnitude oft he problem is only truly appreciated factors present in each limb has been important in the initial
by excursion into the community. Of the patients included in this successful reduction of the ulcer population. The mechanics of
survey 62 per cent had never attended any hospital despite conducting the study itself, however, initiated a greater liaison
having an open infected wound, half of which had been present between community and hospital services, such that early
for more than one year. Only seven patients were under 40 years referral of all ulcerated limbs is now the rule with immediate

Br. J. Surg., Vol. 73, No. 9, September 1986 695

Leg ulcers: J. V. Cornwall et al.
assessment by the ulcer liaison sister. Following objective
studies undertaken at home, basic problems continue t o be
treated initially in the community, but with a very much greater
likelihood of success. The complex or persistent lesions are
referred without delay for further assessment.
We feel that a suitably qualified and trained district nurse
could pay for herself easily within one year, as o u r conservative
estimate showed the cost of leg ulcer dressings based on
community figures alone to be well in excess off100000 per year
in the District before the study. W e would strongly endorse a
national initiative which would parallel the advances and
understanding of venous pathophysiology and treatment,
bringing leg ulcers and their management out of the Middle
Ages.
Acknowledgements
We would like to thank the General Practitioners of the Harrow Health
District for their assistance, together with the Harrow Area Health
Authority’s District Nursing Service, without whom this survey would
not have been possible. Our thanks are also due to: David Goss, ex-
blood Flow Technician, Northwick Park Hospital and Mrs P. A. Jones
for secretarial help.
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Paper accepted 7 April 1986
Br. J. Surg., Vol. 73, No. 9, September 1986