Martorell's Ulcer Revisited

Steven Davison, MD, DDS, Edward Lee, MD, Edward D Newton, MD

Disclosures

Wounds. 2003;15(6) 

In This Article

Case Report

A 59-year-old Caucasian woman presented with a five-centimeter-diameter superficial ulcer on the anterolateral aspect of her left leg. The patient stated the ulcer had developed after minimal trauma (Figure 1). The wound failed to respond to extensive antibiotic therapy, local wound care, and application of local tissue growth factors by her previous physician. The patient denied a history of diabetes or peripheral vascular disease. On physical exam, the patient had significant hypertension with a diastolic blood pressure greater than 120mmHg despite antihypertensive therapy with a calcium channel blocker. The anterolateral supramalleolar region of the contralateral leg had a healed ulcer that had been covered with a skin graft three years earlier. There were no signs of venous stasis, such as edema or brawny induration. The patient had palpable pedal pulses and a normal ankle/brachial index (ABI). The patient was a smoker, and Beurger's disease was considered. The patient ceased all use of tobacco while being treated, but this did not lead to resolution of the ulcer. The ulcer was treated with debridement, elevation, and wet-to-dry saline dressings. The wound continued to progress. Factitious injury was eliminated with occlusive dressing while a negative hematologic and rheumatologic workup was completed. The wound had progressed with peroneus brevis and peroneus longus tendon exposure. Arteriogram did not indicate any significant arterial insufficiency. Attempted radial forearm free flap coverage of the 8cm x 7cm ulceration failed at post-operative Day 6 from venous stasis secondary to an extended period of dependency. The ulcer was progressive, particularly at the margins where tissue may have been traumatized during operation. Telltale satellite lesions developed (Figure 2). A biopsy of the ulcer exhibited hyalinization and thickening of the arteriole media (Figure 3). Quantitative and qualitative wound cultures exhibited superficial colonization with no deep infection. A Martorell's ulcer was suspected at this time, and aggressive antihypertensive therapy with clonidine, an ACE inhibitor, and a beta-blocker was initiated. The patient's diastolic blood pressure stabilized to < 80mmHg. The wound progression was arrested. Conservative wound care and judicious skin grafting healed the wound over four months. During hospitalization, the patient experienced severe pain that was out of proportion to the injury and required constant opiates and an epidural bupivicaine infusion to gain control. The wound has remained healed, and the patient's blood pressure has remained stable for several years (Figure 4).

This was the original wound. A distal extremity ulcer developed after mild trauma.

This photo shows the wound progression. The wound edge and satellite areas underwent infarction after mild trauma.

A biopsy of the ulcer exhibited hyalinization and thickening of the arteriole media.

This photo shows the healed wound.

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