Leg Ulcer Leg Ulcer ManagementManagement

Lets Go!Lets Go!

Leg Ulcer ManagementLeg Ulcer ManagementAimsAims

Revise the Revise the pathophysiology pathophysiology of venous and of venous and arterial Ulcersarterial UlcersReview the Review the process of process of assessmentassessment

OutcomesOutcomes

Demonstration of Demonstration of Doppler Ultra Doppler Ultra SoundSoundManagement of Management of leg ulcersleg ulcersWhere to from Where to from here?here?

What is a leg Ulcer?What is a leg Ulcer?It is a breach in the integrity It is a breach in the integrity of the skin in the lower limbs, of the skin in the lower limbs, usually below the knee. Many usually below the knee. Many ulcers can start as a scratch ulcers can start as a scratch or tear in the skin and due to or tear in the skin and due to other contributing factors other contributing factors present, may progress to an present, may progress to an ulcer in 6 weeks.ulcer in 6 weeks.

Venous leg ulcersVenous leg ulcers..

Located in the gaiter areaLocated in the gaiter areaShallow in appearance Shallow in appearance sometimes with diffuse sometimes with diffuse edgesedgesOedema usually presentOedema usually presentOften highly exuding Often highly exuding woundswounds30% of pts suffer with 30% of pts suffer with painpainAccompanied by Varicose Accompanied by Varicose VeinsVeinsPulses can be palpated in Pulses can be palpated in the absence of oedema the absence of oedema

You may see ankle flareYou may see ankle flareLipodermatosclerosisLipodermatosclerosisUlcers can be multiple or Ulcers can be multiple or circumferential.circumferential.There can be eczema There can be eczema present, venous or present, venous or gravitational.gravitational.Haemosidrin staining can Haemosidrin staining can be present (looks like rust)be present (looks like rust)There may also be atrophy There may also be atrophy blanche.blanche.Approximately 50% of Approximately 50% of ulcers are venous.ulcers are venous.

Arterial ulcersArterial ulcersLocated on any part of Located on any part of the leg, most common the leg, most common on or below the ankle.on or below the ankle.Small and punched Small and punched out appearance.out appearance.Oedema is generally Oedema is generally localised to the localised to the wound.wound.Tendency to be dry Tendency to be dry wounds.wounds.Slow capillary refill.Slow capillary refill.

Usually very painful Usually very painful ulcers, mostly at ulcers, mostly at night.night.Leg can be shiny, Leg can be shiny, tight, hairless and tight, hairless and cold.cold.Pulses are reduced Pulses are reduced and/or absent.and/or absent.You may see trophic You may see trophic changes to the nailschanges to the nailsRuborRuborApproximately 30% of Approximately 30% of leg ulcers are arterial.leg ulcers are arterial.

What are the other types of What are the other types of Leg Ulceration?Leg Ulceration?

Diabetic Diabetic -- Poor/ compromisedPoor/ compromised peripheralperipheralcirculation (Necrobiosis Lipoidica)circulation (Necrobiosis Lipoidica)Rheumatic Arthritis Rheumatic Arthritis -- Calcification of Calcification of blood vessels usually in the arterial treeblood vessels usually in the arterial treeMalignancy Malignancy -- SCC, BCC, Melanoma & SCC, BCC, Melanoma & CTCLCTCLUnderlying Disease Underlying Disease –– Pyoderma Pyoderma Gangrenosum, Mental Health (Artefact), Gangrenosum, Mental Health (Artefact), Eczema Craquele/dependant oedema, Eczema Craquele/dependant oedema, Sickle Cell and thalassemia Sickle Cell and thalassemia

Holistic AssessmentHolistic AssessmentHolistic assessment is key , accurate Holistic assessment is key , accurate identification of the underlying pathophysiology identification of the underlying pathophysiology of the ulceration leads to the provision of the of the ulceration leads to the provision of the optimal treatment.optimal treatment.Patient history of the woundPatient history of the woundSocial history, what was or is the patients Social history, what was or is the patients occupation? occupation? Medical history, get the pts perspectiveMedical history, get the pts perspectiveObservationsObservations

1.1. Blood pressureBlood pressure2.2. TemperatureTemperature3.3. PulsePulse4.4. Urinalysis or Bm checkUrinalysis or Bm check5.5. Height or weight, might need an MNAHeight or weight, might need an MNA

Holistic Assessment.Holistic Assessment.Varicosities and or staining (haemosidrin Varicosities and or staining (haemosidrin deposits)deposits)Lipodematosclerosis, fibrosis of the dermis and Lipodematosclerosis, fibrosis of the dermis and sub cutis, with induration(hardening)sub cutis, with induration(hardening)OedemaOedemaEczema or HyperkeratosisEczema or HyperkeratosisRubor, redness of the limb when dependantRubor, redness of the limb when dependantAtrophy blanche, avascular areas of white tissue, Atrophy blanche, avascular areas of white tissue, lace like scarringlace like scarringAnkle flare, dilated venuoles and capillaries Ankle flare, dilated venuoles and capillaries adjacent to the medial malleolus and extending adjacent to the medial malleolus and extending towards the sole of the foot.towards the sole of the foot.

Holistic AssessmentHolistic AssessmentWhat are the coWhat are the co--morbiditiesmorbiditiesWhat is the ankle movement likeWhat is the ankle movement likeAssess the pain, what eases the Assess the pain, what eases the pain, elevation or lowering of the pain, elevation or lowering of the legs?legs?Medication history.Medication history.Lab tests if required (FBC ESR)Lab tests if required (FBC ESR)Look at the wound itself and the peri Look at the wound itself and the peri wound skin.wound skin.

Doppler ultra sound.Doppler ultra sound.

In 1842 Anston Doppler described In 1842 Anston Doppler described the the ’’Doppler effectDoppler effect’’, Where there is a , Where there is a change in the pitch of a note when change in the pitch of a note when approaching or receding from the approaching or receding from the listener. This sound is measured in listener. This sound is measured in Hertz and the pitch of the note Hertz and the pitch of the note depends on the number of vibrations depends on the number of vibrations that reach the ear in a second.that reach the ear in a second.

Doppler Ultra SoundDoppler Ultra SoundThe holistic assessment should indicate the type of ulcer we The holistic assessment should indicate the type of ulcer we

are dealing with, Doppler U/S confirms our diagnosis.are dealing with, Doppler U/S confirms our diagnosis.

Doppler is contra indicated in these casesDoppler is contra indicated in these casesDVT real or suspectedDVT real or suspectedWhere pt is unable to lie flat (COAD)Where pt is unable to lie flat (COAD)Pain on inflation of the cuff.Pain on inflation of the cuff.

The Ankle Brachial Pressure index is measured by dividing the The Ankle Brachial Pressure index is measured by dividing the arm pressure by the leg pressure, just remember to arm pressure by the leg pressure, just remember to

Get your leg overGet your leg over

Doppler ultra sound.Doppler ultra sound.

The Doppler unit mostly used in the The Doppler unit mostly used in the DHB I work in is the Huntleigh hand DHB I work in is the Huntleigh hand held unit, It consists of a transducer held unit, It consists of a transducer probe with lead attached to an audio probe with lead attached to an audio unit. The probes can be changed as unit. The probes can be changed as you will require a different probe for you will require a different probe for a specific conditiona specific condition8mhz for a normal limb8mhz for a normal limb5mhz for an oedematous limb.5mhz for an oedematous limb.

Doppler ultra soundDoppler ultra soundThe Doppler will detect arterial and venous blood The Doppler will detect arterial and venous blood flow but the sounds will be very different, arteries flow but the sounds will be very different, arteries emit a very strong pulsatile sound and veins give emit a very strong pulsatile sound and veins give a roaring or whooshing sound, we are measuring a roaring or whooshing sound, we are measuring the systolic blood pressure of the arteries.the systolic blood pressure of the arteries.

An ABPI of An ABPI of <0.3 Critical Ischemia (refer immediately)<0.3 Critical Ischemia (refer immediately)<0.7 Moderate Ischemia (Vascular out patients)<0.7 Moderate Ischemia (Vascular out patients)1.0 1.0 –– 0.7 Could be mildly ischemic, reduce oedema 0.7 Could be mildly ischemic, reduce oedema and recheck Doppler's.and recheck Doppler's.>1.5 May not be able to occlude the arteries ? Due to >1.5 May not be able to occlude the arteries ? Due to calcification, refer to VOPC calcification, refer to VOPC

Management of leg Management of leg ulceration.ulceration.

Management is as holistic as assessment Management is as holistic as assessment for all types of leg ulcer, the diagnosis for all types of leg ulcer, the diagnosis and the treatment options available can and the treatment options available can be specific to the aetiology of the ulcer, be specific to the aetiology of the ulcer, but we have to consider other factors but we have to consider other factors which go into holistic management. which go into holistic management. These other aspects can be as simple as These other aspects can be as simple as getting the correct dressing product for getting the correct dressing product for the wound, and as difficult as referrals the wound, and as difficult as referrals for orthotic footwear.for orthotic footwear.

Holistic management.Holistic management.Enable the patient to exercise, there may be Enable the patient to exercise, there may be cause for a green prescription, podiatry may be cause for a green prescription, podiatry may be indicated or correct footwear.indicated or correct footwear.It may need a referral to another service, such as It may need a referral to another service, such as the District Nurses, vascular surgeons or the District Nurses, vascular surgeons or dermatology.dermatology.Diet is important, weight loss may be indicated, Diet is important, weight loss may be indicated, there could be another referral to dietetics.there could be another referral to dietetics.Health promotion is important, smoking cessation Health promotion is important, smoking cessation for a client with arterial disease.for a client with arterial disease.Drinking excessive amounts of alcohol will Drinking excessive amounts of alcohol will exacerbate skin conditions such as psoriasis, exacerbate skin conditions such as psoriasis, working with a patient to reduce alcohol intake working with a patient to reduce alcohol intake would be very beneficial.would be very beneficial.

Holistic management.Holistic management.A medication review may be necessary as A medication review may be necessary as a number of medications impair or a number of medications impair or suppress healing, such as steroids and suppress healing, such as steroids and cytotoxic drugs.cytotoxic drugs.The factors which may be uppermost in The factors which may be uppermost in your patients mind are the social ones your patients mind are the social ones such as having to take time off work, the such as having to take time off work, the loss of earnings. This may necessitate a loss of earnings. This may necessitate a referral to WINZ or we can try working referral to WINZ or we can try working around the patients schedule.around the patients schedule.The aesthetic considerations of the look of The aesthetic considerations of the look of treatment. Not everyone wants the world treatment. Not everyone wants the world to know they have a leg ulcer.to know they have a leg ulcer.

Skin CareSkin CareSkin care is of vital importance in the treatment Skin care is of vital importance in the treatment of leg ulcers (and chronic wounds)of leg ulcers (and chronic wounds)Careful choice of wound product, noting Careful choice of wound product, noting patients professed allergies.patients professed allergies.Allowing a pt to shower.Allowing a pt to shower.Choice of emollient is dependant on peri wound Choice of emollient is dependant on peri wound skin condition and pt choice skin condition and pt choice

1.1. Lotions Lotions –– these evaporate very quickly and cool the skin, great these evaporate very quickly and cool the skin, great for inflamed areasfor inflamed areas

2.2. Creams Creams –– mostly water so help to re establish moisture to the mostly water so help to re establish moisture to the skin, they are easy for pts to wash offskin, they are easy for pts to wash off

3.3. Gels Gels –– now much more common, cooling and non greasynow much more common, cooling and non greasy4.4. Ointments Ointments –– Semi solid grease or oil with very little water, they Semi solid grease or oil with very little water, they

occlude water loss and re establish the lipid layer in the skin,occlude water loss and re establish the lipid layer in the skin,very good to use when the area is dampvery good to use when the area is damp

Steroid UseSteroid Use1.1. Mild Mild –– Hydrocortisone 1 to Hydrocortisone 1 to

2.5 %2.5 %2.2. Moderate Moderate –– EumovateEumovate3.3. Potent Potent –– Betnovate, locoidBetnovate, locoid4.4. Very potent Very potent –– DermovateDermovate

Apply using the Finger Apply using the Finger Tip unit rule! Tip unit rule!

1FTU = 1FTU = ½½ gram gram Steroids are meant to be Steroids are meant to be

applied sparingly and applied sparingly and up to 2 times per day.up to 2 times per day.

RememberRememberThe skin can atrophy, The skin can atrophy, and become inflamed and become inflamed by over use of steroidby over use of steroidSteroids can induce Steroids can induce acne or rosaceaacne or rosaceaFungal infections can Fungal infections can be potentiatedbe potentiatedAllergies exist to Allergies exist to steroidssteroidsThere is a risk of There is a risk of systemic absorptionsystemic absorptionTachyphylaxis reduced Tachyphylaxis reduced response to steroidsresponse to steroids

Compression therapy.Compression therapy.Most research on leg ulcer management is Most research on leg ulcer management is from the UK, published by the RCN and from the UK, published by the RCN and SIGN.SIGN.Within the UK the NHS spends Within the UK the NHS spends approximately 1 billion pounds per year on approximately 1 billion pounds per year on chronic wound care and 400million of that chronic wound care and 400million of that is for leg ulcer management.is for leg ulcer management.There is very little statistical information There is very little statistical information from NZ on the health care spend for Leg from NZ on the health care spend for Leg ulcers.ulcers.There is a guideline from the New Zealand There is a guideline from the New Zealand guideline group, available on the internet guideline group, available on the internet at at www.nzgg.org.nzwww.nzgg.org.nz

Compression therapyCompression therapyThe theory of compression therapy is The theory of compression therapy is that it willthat it will

1.1. Counteract the increased pressure in the Counteract the increased pressure in the superficial veins and reduce the superficial veins and reduce the distension in these veins.distension in these veins.

2.2. Encourage and enhance blood flow Encourage and enhance blood flow velocity in the veins.velocity in the veins.

3.3. Discourage ankle swelling, reducing the Discourage ankle swelling, reducing the pressure differences between the pressure differences between the capillaries and the tissues, thus restoring capillaries and the tissues, thus restoring the rate of tissue fluid formation towards the rate of tissue fluid formation towards normal.normal.

Laplaces lawLaplaces lawLaplaces law is the mathematics behind Laplaces law is the mathematics behind compression therapy.compression therapy.It can be explained in the equation It can be explained in the equation

P=N*T/C*WP=N*T/C*WWhere P= Pressure of the bandageWhere P= Pressure of the bandage

N= Number of layersN= Number of layersT= Tension of bandagesT= Tension of bandagesC= Circumference of the limbC= Circumference of the limbW= Width of the bandages.W= Width of the bandages.

It basically means that sub bandage pressure is It basically means that sub bandage pressure is directly proportional to the bandage tension directly proportional to the bandage tension (during application) and the number of layers (during application) and the number of layers applied, and inversely proportionate to the applied, and inversely proportionate to the curvature of the limb. The pressure lessens as curvature of the limb. The pressure lessens as you bandage up from the ankle.you bandage up from the ankle.

BandagingBandaging4 Layer compression 4 Layer compression therapy is still the gold therapy is still the gold standard in treatment of standard in treatment of venous and mixed venous and mixed ulceration.ulceration.It provides graduated It provides graduated compression, the highest compression, the highest mmhg at the ankle, with mmhg at the ankle, with approx approx ½½ that at the top that at the top of the calf. Compression of the calf. Compression reduces the venous reduces the venous hypertension within the hypertension within the vascular system byvascular system byReducing the diameter of Reducing the diameter of major blood vessels, major blood vessels, thereby reducing the local thereby reducing the local blood volume.blood volume.Improving lymph Improving lymph drainage, by reducing drainage, by reducing lymph in the tissues.lymph in the tissues.Reducing venous stasisReducing venous stasis

There are many different There are many different types of compression that types of compression that we can employwe can employ4 layer/ multilayer 4 layer/ multilayer systemssystemsInelastic or short stretchInelastic or short stretch3 layer tubigrip and 3 layer tubigrip and shaped tubigripshaped tubigripHighly elastic bandages, Highly elastic bandages, tensopress and surepress.tensopress and surepress.

Modified compression is Modified compression is used to achieve used to achieve compliance and remove compliance and remove oedema when the oedema when the diagnosis is of mixed diagnosis is of mixed aetiology, it also helps to aetiology, it also helps to achieve pain control. 3 achieve pain control. 3 layer compression is not layer compression is not heavily dependant onheavily dependant onankle size.ankle size.

BandagingBandaging3 layer systems3 layer systems

Sofban, shapes, protects Sofban, shapes, protects and absorbs.and absorbs.Crepe is purely a retention Crepe is purely a retention bandage.bandage.Coban is a 3b classified Coban is a 3b classified bandage and gives ~ 23 to bandage and gives ~ 23 to 25 mmhg on an ankle that 25 mmhg on an ankle that is size 18 to 25 cm, is size 18 to 25 cm, therefore it follows that the therefore it follows that the compression would be compression would be more on a thinner ankle more on a thinner ankle and less on a larger ankle.and less on a larger ankle.

4 Layer systems (184 Layer systems (18––25)25)Sofban, shapes, protects Sofban, shapes, protects and absorbs.and absorbs.Crepe, purely retention.Crepe, purely retention.Elset or profore # 3, apply Elset or profore # 3, apply in a figure of 8 it provides in a figure of 8 it provides twice as much twice as much compression, 15 to 17 compression, 15 to 17 mmhgmmhgCoban, spiral toe to knee it Coban, spiral toe to knee it provides 23 to 25 mmhg provides 23 to 25 mmhg compression. Elset and compression. Elset and Coban combined provides Coban combined provides 40 mmhg of compression 40 mmhg of compression at the ankle, gradually at the ankle, gradually lessening to approx 15 to lessening to approx 15 to 20 mmhg at the proximal 20 mmhg at the proximal calf.calf.

BandagingBandagingShort stretch bandages are now more Short stretch bandages are now more common as they an be washed and reused common as they an be washed and reused up to 20 times.up to 20 times.They provide up to 60 mmhg of They provide up to 60 mmhg of compression when the patient is active, compression when the patient is active, the bandage creates an antagonist against the bandage creates an antagonist against which the calf muscle pump can work.which the calf muscle pump can work.The sub bandage pressures are lower at The sub bandage pressures are lower at rest, meaning less pain at night.rest, meaning less pain at night.Short stretch bandaging is used to good Short stretch bandaging is used to good effect when the shape of the leg require effect when the shape of the leg require specific padding for 4 layer compression.specific padding for 4 layer compression.

BandagingBandagingFor arterial ulcers if the ABPI indicates you For arterial ulcers if the ABPI indicates you can use modified compression, 3 layer or can use modified compression, 3 layer or a tubular bandage.a tubular bandage.Though you need to be aware that arterial Though you need to be aware that arterial ulcers should, if they are to be bandaged, ulcers should, if they are to be bandaged, be padded with a toe to knee layer of be padded with a toe to knee layer of sofban and then crepe toe to knee, to sofban and then crepe toe to knee, to prevent the tourniquet effect.prevent the tourniquet effect.However the most important thing to However the most important thing to remember is that patient concordance is remember is that patient concordance is essential, so the treatment must be essential, so the treatment must be agreed upon by both the practitioner and agreed upon by both the practitioner and the patient.the patient.