Martorell's Ulcer Revisited

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


Wounds. 2003;15(6) 

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This case report is nearly classic in its description. The wound was on the anterolateral lower third of the leg and had bilateral symmetry, the patient had poorly controlled hypertension, the patient was a woman between the ages of 55 and 65, she had pain out of proportion to wound size, and the wound only healed after adequate control of hypertension. A recent review by Graves listed five defining characteristics of Martorell's ulcers, as follows: 1) There is moderate to severe pain that is often greater than expected based on ulcer size. This pain is often difficult to manage. 2) The ulcer occurs in a specific location on the lower extremity. The lesion was originally described on the anterolateral aspect of the lower third of the leg, but has been reported on the posterior and anterior aspect of the leg as well as one case on the thigh.[6] 3) There is a female to male predominance of 83 to 23 out of the 106 cases reported in the world's English literature. There is also a predilection for the age group between the mid 50s and mid 60s. 4) Patients will also often have poorly controlled hypertension, particularly diastolic hypertension. 5) Healing only occurs in response to adequate control of hypertension. These criteria are similar to the criteria originally described by Hines and Farber.[2]

The diagnosis of a Martorell's ulcer also requires exclusion of infectious, rheumatologic, endocrine, and other vascular causes.[5] Sheps found a high association of comorbidities, including atherosclerosis, stasis ulcers, and diabetes, all of which can lead also to skin lesions.[6] Therefore, it is important to exclude these diagnoses in particular. Sheps stated that a highly characteristic feature of hypertensive ulcers was the episodic and irregular extension of skin infarction at the wound edges and the development of satellite lesions. This disease progression was observed in this case. In addition, this ulcer required four months to heal, which is similar to the classical time frame described for such an ulcer.

The existence of Martorell's ulcer as a unique disease entity has been questioned.[7] Leu and others have shown that the vascular changes in these ulcers are similar to those changes found in other organs of hypertensive patients. Histologic examination showed a classic hyalinization and thickening of the arteriole media with absence of atheroma and calcification. There was no evidence of perivascular invasion as would be seen in vasculitis, such as pyoderma gangrenosum. Analysis of hypertensive ulcers shows a pathologic process that is different from atherosclerotic disease and stasis ulcers.

Although there is similarity to other hypertensive arteriolar changes, Duncan identified a decrease in skin perfusion pressure that was unique to patients with Martorell's ulcer when compared to those with peripheral vascular disease. Perfusion of the skin was measured through an intradermal injection of 99mTc as a plastic bag held by a standard sphygmomanometer cuff was used to tamponade flow at varying pressures. Duncan's study[8] found decreased skin perfusion pressure in patients with Martorell's syndrome that paradoxically correlated with increased ankle brachial indexes. The hypertensive ulcers may have a higher vascular resistance due to a decrease in the compensatory dilatation of the arterioles supplying the dermal capillary bed. Transcutaneous oxygen perfusion was not measured over the Martorell's ulcers.

After the correct diagnosis is made it is essential to minimize tissue trauma. Surgical debridement or flap coverage appears to exacerbate the condition by traumatizing and thus involving the wound edges in the pathologic process. The key to successful wound healing is medical management of the hypertension and conservative wound care. In this case, padded cast dressings were used to protect the wound and allow reepithelization, and the patient's blood pressure was aggressively managed with the diastolic pressure kept under 80mmHg.

Historically, distal extremity ulcers secondary to hypertension were treated with surgical sympathectomy. However, newer antihypertensive and analgesic techniques, such as a bupivicaine epidural, can provide both pharmacological sympathectomy as well as excellent pain control. Moreover, in the long term, newer antihypertensive medications, such as angiotensin converting enzyme inhibitors, angiotension receptor blockers, and calcium channel blockers, can be used to control the presumed underlying cause of these ulcers.

This case emphasizes the need for clinical suspicion of Martorell's Ulcer in complex, recalcitrant, painful, anterolateral leg wounds, particularly when the stigmata of atherosclerotic or venous stasis disease are absent. Aggressive medical control of the patient's blood pressure is paramount to healing Martorell's ulcers, while surgical management must be extremely conservative to avoid wound exacerbation. Martorell's hypertensive ulcer is a unique disease, the rarity of which makes it difficult to recognize.