What are the characteristic features of an arterial ulcer in a patient with peripheral arterial disease (PAD)?

Arterial Ulcer Characteristics

The correct answer is B: arterial ulcers are commonly found in the distal parts of the extremity as a result of a proximally significant stenosis. 1

Key Distinguishing Features of Arterial Ulcers

Location and Pathophysiology

• Arterial ulcers occur in distal extremities (toes, feet, heels) due to inadequate perfusion from proximal arterial stenosis or occlusion 1, 2, 3
• The distal location reflects the "end-organ" nature of ischemic tissue damage where blood flow is most critically reduced 4, 2

Appearance and Characteristics

• Arterial ulcers are NOT "beefy red" and moist - this description characterizes venous ulcers, not arterial ulcers 1
• Arterial ulcers typically present with pale, dry wound beds with minimal granulation tissue 2, 3
• The wound borders are often well-demarcated and "punched out" in appearance 3
• In the absence of neuropathy, arterial ulcers are exquisitely painful and tender to palpation 1

Associated Symptoms

• Pain is typically WORSE with leg elevation and IMPROVED with dependency - the exact opposite of venous disease 5, 6
• Critical limb ischemia presents with rest pain that is worse when supine and lessened with limb dependency 5
• Patients may report claudication (exertional leg pain) or ischemic rest pain preceding ulcer development 2, 3

Physical Examination Findings

• Diminished or absent pulses distal to the occlusion 1
• Cool skin temperature in the affected extremity 5, 7
• Dependent rubor (reddish discoloration when dependent) and early pallor on elevation 1
• Trophic changes including distal hair loss, hypertrophic nails, and shiny, atrophic skin 1

Why the Other Options Are Incorrect

Statement A is False

• "Beefy red" and moist with irregular borders describes venous ulcers, not arterial ulcers 1
• Arterial ulcers have pale, dry bases with well-demarcated borders 2, 3

Statement C is False

• Leg pain/swelling relieved by elevation is characteristic of venous insufficiency, not arterial disease 8
• Arterial ischemic pain is worsened by elevation and improved by dependency 5, 6

Critical Diagnostic Pitfall

• In diabetic patients with neuropathy, arterial ulcers may be painless despite severe ischemia, potentially delaying diagnosis and treatment 1, 5
• These patients require objective vascular assessment (ankle-brachial index, toe pressures) rather than relying on symptom history alone 1, 7