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South West Regional Wound Care Toolkit

SWRWC Toolkit B.2.1 Lower Leg Assessment: Purpose and Instructions_July-10_2011

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B. 2. INTERDISCIPLINARY LOWER LEG ASSESSMENT

2.1 Purpose and Instructions for the Lower leg Assessment Tool

Purpose

This tool is to assist the nurse in assessment of the lower leg and in particular, to identify and document

any abnormality of the lower leg and contains recommendations for actions based on abnormal

findings.

Instructions

Please include the individual’s demographics at the top right hand corner of the tool, either with an

identifier sticker/addressograph or by printing the information in by hand.

Sections a-l: This is to be used by a qualified health care professional (see Competency Levels in

Introduction to Toolkit) to do a thorough assessment of the lower leg when an ulcer is present and/or

when peripheral or arterial issues are noted.

Sections m- p: A Wound Care Specialist is required to complete. While a Wound Care Specialist nurse

may not diagnose, they can assess characteristics to allow them to request further investigations in

order for the physician to form a definitive diagnosis.

Please note: Patient permission was received to use all photos contained in this document for

educational purposes.

a. Ulcer or pre-ulcerous conditions

Please add the history of previous ulcer(s) and date of onset of the new ulcer(s)/pre-ulcerous

condition(s). If there are numerous sites, please list. Use the tick boxes to identify characteristics of the

ulcer and surrounding skin.

b. Pain (specific to legs)

Check off the box that identifies the type of pain the patient is experiencing. If pain is uncontrolled use

the tick box to indicate that you are requesting or referring to pain specialist to address control.

Pain occurs in as much as 76% of venous ulcers. Deep ulcers, particularly those around the malleolus, or

small ulcers surrounded by atrophie blanche are the most painful.

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c. Foot Deformities, Nails and Footwear

Use the check boxes to check off all those that apply when examining the foot

Foot Deformities

Description Examples

Hammer toes - in a hammertoe

deformity, the first joint (MTP) is

cocked upward, and the middle joint

(PIP) bends downward.

Illustration used with permission of artist Nancy Bauer

and the Registered Nurses’ Association of Ontario

(2005). Assessment & Management of Foot Ulcers for

People with Diabetes. Toronto, Canada: Registered

Nurses’ Association of Ontario.

Hallux valgus (bunion deformity) –

occurs when the great toe begins to

deviate, developing a firm bump on the

inside edge of the foot. It is not painful

at first, but when the toes deviate even

more, redness, swelling and pain at or

near the joint occur. The pain is caused

by pressure of the footwear on the

bunion or from the pressure inside the

joint. Hallux valgus describes the

change in position of the toe, and

bunion describes the bump on the foot.

http://www.epodiatry.com/bunion.htm Illustration used with permission of artist Nancy Bauer





Fixed ankle joint- Fibrous or bony

ankylosis at the ankle can occur

because of immobility (joint assumes

the least painful position and becomes

fixed). In venous insufficiency, fibrotic

tissue deposits due to

lipodermatosclerosis also decrease

ankle mobility—lose ability to dorsiflex.

This decreases the chance of healing by

70%.

No illustration available

Hallus Valgus or Large

Bunion (Severe) –big toe

may move under

second toe

Halgus Valgus or Small

Bunion(Mild/Moderate)

– joint at the base of big

toeis pushed to the side



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Claw toes - A claw toe deformity

has a cocked up MTP joint, and both

the middle joint (PIP) and the tiny joint

at the end of the toe (the DIP) are

curled downward like a claw. Illustration used with permission of artist Nancy Bauer





Hallus rigidus – caused by

osteoarthritis in the MTP joint at the

base of the big toe, causing pain and

loss of motion in the MTP joint.


Dropped arch- Pes Planus also

called “fallen arches or flat foot” Drawing used with permission of artist Nancy Bauer

and the RNAO (2005). Assessment & Management of

Foot Ulcers for People with Diabetes. Toronto, Canada:

Registered Nurses’ Association of Ontario.

Dropped MTH – Pes Cavus—the

arch is abnormally high, with the

forefoot extended below. The toes are

often clawed. Illustration used with permission of artist Nancy Bauer





Charcot Joint- a form of

neuroarthropathy. Nerve damage

causes the ligaments and muscles to

atrophy, which causes joint instability.

Walking on this without proper

protection causes more damage to the

foot structure. In advances state, the

sole of the foot forms a rocker shape,

increasing the risk of ulceration. Illustration used with permission of artist Nancy Bauer





Charcot Arthropathy

Claw Toe

Pes Planus

Pes Cavus



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Corns -

A corn is thickened skin on the top or

side of a toe, usually from shoes that do

not fit properly. Corns may cause

discomfort, while calluses normally do

not.

Example of corn with ulceration:

Calluses-

A callus is thickened skin on your the

soles of the feet, caused when there is

foot deformity secondary to

neuropathy or other causes. Sensory

neuropathy eliminates the protective

painful signal caused by tissue damage

while motor neuropathy leads to

muscle atrophy, foot deformity, altered

biomechanics, and increased plantar

pressure. The increased local plantar

pressure and trauma is associated with

callus formation that usually precedes

skin breakdown. Without callus

debridement and pressure relief the

persons with diabetes develop chronic

non-healing ulceration.

Examples:

Fissures – these commonly occur

on the heels, but can develop

elsewhere on the foot if there is

thickened hyperkeratotic skin caused

by dryness, walking barefoot or

wearing sandals or open-backed shoes

or from inactive sweat glands caused by

neuropathy. These can pose a serious

risk as they can be a pathway for

bacteria and infection.

Footwear Assessment:

Orthotics not being worn at all times, indoor or out: the purpose of orthotics is to help distribute

pressure away from the areas of higher pressure. If they are not worn at all times, the benefit is

significantly reduced. It is important to redistribute plantar pressure with the use of various walking

devices and footwear. This step is critical for the prevention of pressure build up and callus formation by

cushioning, accommodating, realigning, stabilizing, and unloading rigid or deformed structures.



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Inappropriate footwear- e.g. high-heeled or narrow-toed shoes may cause pressure areas. If the

toes are squeezed or pinched together, the bony prominences of the toes can cause pressure ulcers.

Presence of pressure areas: document any areas of redness

d. Test for Neuropathy

To test for neuropathies use a monofilament (available at

http://www.cawc.net/images/uploads/Order_Form.pdf). The filament is

pressed against part of the foot. When the filament bends, its tip is exerting a

pressure of 10 grams (therefore this monofilament is often referred to as the

10 gram monofilament). If the patient cannot feel the monofilament at certain

specified sites on the foot, he/she has lost enough sensation to be at risk of

developing a neuropathic ulcer. Please refer to the diagram in the tool for the

10 pressure points to test. Score is out of ten.

Please check off any other sensory and motor findings.

Please refer to a foot specialist if there is a loss of protective sensation and refer to an OT if underlying

pressure and/or surface concerns.

e. DIABETIC FOOT RISK CLASSIFICATION SYSTEM: The International Working Group Original and

Modified Criteria 2010

Use the International Working Group on the Diabetic Foot Risk Classification System: Modified Criteria

2010

Indicate the level of risk that you have identified based on your findings.

f. The University of Texas Staging System for Diabetic Foot Ulcers (only for clients with Diabetic Foot

Ulcer)

Describe the Stage and Grade of the ulcer based on the descriptors in the chart.

g. Edema (if present)

Check off all areas affected.

Pitting edema can be demonstrated by

applying pressure to the swollen area by

depressing the skin with a finger x 10 – 15 seconds.

If the pressing causes an indentation that persists

for some time after the release of the pressure,

the edema is referred to as pitting edema. It is

graded based on the depth of the indentation:

1+ = 0 - ¼” 2+ = ¼” – ½” 3+ = ½ - 1” 4+

= takes several minutes to rebound



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In non-pitting edema, pressure that is applied

to the skin does not result in a persistent

indentation. Non-pitting edema can occur in

certain disorders of the lymphatic system such as

lymphedema, where edema is particularly

prominent on the dorsum of the feet and in the

toes.

Brawny Induration - Brawny means swollen

and hardened, while induration is abnormal

firmness of tissues with margins. Palpate where it

starts and stops. Induration results in an inability

to pinch the tissues.

h. LYMPHEDEMA ASSESSMENT *NB- individuals can have symptoms of both venous disease &

lymphedema or lymphedema & lipedema

Check off all areas affected- descriptors are present in the tool.

i. LIPEDEMA ASSESSMENT *NB- individuals can have symptoms of both lymphedema & lipedema

Check off all areas affected- descriptors are present in the tool.

j. Skin & Anatomy

Check off all venous and arterial signs and symptoms observed. Signs of arterial disease will warrant

further investigation of peripheral arterial status.

Signs and Symptoms of Venous Disease: Check off all areas affected- descriptors are present in the

tool.

Descriptors Examples

Varicosities- either small or larger vessels



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Hemosiderin staining- Brown or brownish red pigmentation

and purpura caused by extravasation of red blood cells into the

dermis

Chronic Lipodermatosclerosis- lower 1/3 of leg becomes

sclerotic and woody. Leg becomes champagne bottle or bowling-

pin shaped – ulcers are more difficult to heal.

Acute lipodermatosclerosis- This presents as a painful and

tender condition of the leg. It is frequently misdiagnosed as

cellulitis or morphea. It represents a panniculitis associated with

venous insufficiency. Ulcers can occur within the lesion, which

becomes intensely fibrotic over time.

Photograph used with permission of Dr. V. Falanga. Stasis or venous dermatitis - erythema, scaling, pruritis, and

sometimes weeping- may develop cellulitis through breaks in the

skin.

Atrophie blanche - Located on the ankle or foot, ivory white

lesions, atrophic plaques. Ulcerations tend to be exquisitely

painful. The white lesions represent scarring from previous

injuries.

Woody fibrosis - deposits of fibrin in the deep dermis and fat

results in a woody induration of the gaiter area of the leg



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Ankle (submalleolar) flare - Incompetence in perforating vein

valve which results in venous hypertension and causes dilation of

the venules

Ulcer base moist with granulation &/or yellow slough/ fibrin

Ulcer located in gaiter region (lower 1/3 of calf) - Ulceration

usually on the medial lower leg superior to malleolus but can be

on lateral aspect as well. Ulcerations may encircle the entire ankle;

ulcers occurring above mid-calf or on the foot likely have other

origins.

Ulcer located superior to the medial malleolus

Scarring from previous ulcer(s)- evidence of previous

ulcerations noted

Signs and Symptoms of Arterial Disease:

Descriptors Examples

Hairless –little or no hair on the lower legs or feet


Thin- skin appears thin and fragile and pale in colour


Shiny skin on legs and feet




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Dependent rubor – occurs in the presence of arterial

compromise and can mimic cellulitis. The rubor disappears when

the foot is elevated, which would not happen with cellulitis. It can

be bilateral.

(Gangrene also present)

Blanching on elevation -- occurs in the presence of arterial

compromise and represents decrease in arterial flow without the

gravitational effect of having the foot below the level of the heart.

It can be bilateral.

(Gangrene also present)

Feet cool/cold/blue—this occurs in the presence of arterial

disease, often just involving one leg or foot in comparison to the

other.


Toes cool/cold/blue- in this photograph, the 4th

toe is

becoming ischemic secondary to infection.

Lower temperature in one leg compared to other—one leg

feels cooler than the corresponding area on the other leg – this

generally suggests the presence of PAD in the cooler leg, but can

also be from increased temperature in a leg with infection or

cellulitis.




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Capillary refill time: > 3 seconds

Delayed capillary refill time (CFT) is suggestive of peripheral

arterial disease. Normal CFT is less than 3 seconds.

Photographs used with permission of myfootshop.com

Ulcer located on foot or toes - often on the heels, tips of toes,

between the toes where the toes rub against one another or

anywhere the bones may protrude and rub against bed sheets,

socks or shoes. Definition from : http://my.clevelandclinic.org/heart/disorders/vascular/legfootulcer.aspx

Ulcer base pale and dry &/or contains eschar – the ulcer may

initially have grey or purplish tissue that bleeds very little and will

turn to eschar if allowed to dry out.

Ulcer round and punched out in appearance –arterial ulcers

do not usually have irregular edges and the edges do not slope

gently down to the wound bed

Gangrene dry/wet

Dry gangrene (ischemia) may start out red in colour and cool to

touch, then turn blue or brownish and then becomes black and

will dessicate if allowed to dry.

Wet gangrene (infection causing ischemia) starts out with swelling

and putrifies, may have foul smelling exudate, fever.

Definition from:

http://www.emedicinehealth.com/gangrene/page3_em.htm#Gangrene

%20Symptoms



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Dry & stable gangrene Wet

gangrene

k. UNUSUAL ULCER

The acronym “PULL” can be used to describe unusual ulcers:

“P”urpura,

“U”ndermining border,

“L”ivedo,

unusual “L”ocation)

Dr. Vincent Falanga (Canadian Association of Wound Care conference, 2002)

Examples of Usual Ulcer locations:

Traumatic injuries to the legs often occur in the pre-tibial or calf area as a result of falls or abrasions.

Venous ulcers usually occur superior to the medial malleolus, while pressure ulcers appear on bony

prominences, diabetic foot ulcers on the plantar foot or toes and arterial ulcers or mixed venous arterial

on the lower calf to superior malleolar area.

UNUSUAL locations would be any exceptions to this.

Examples of unusual leg ulcer appearances

Description Examples

Bullous Pemphigus- Chronic, autoimmune, sub-

epidermal, blistering skin disease that rarely

involves mucous membranes. If untreated, the

disease can persist for months or years, with

periods of spontaneous remissions and

exacerbations.

Calciphylaxis- Lesions develop suddenly and

progress rapidly; may be singular or many, and

they usually occur on the lower extremities;

however, may also appear on the hands and

torso. There is intense pain, which may require

pain specialist interventions. Initially they appear

as nonspecific violaceous mottling; as a bluish-red

discolouration of the skin with a characteristic

network pattern (livedo reticularis) or as

erythematous papules, plaques, or nodules. As the

disease progresses, more developed lesions have a

Early stage new lesions



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star-like purple coloured configuration with central

skin necrosis. Less commonly, lesions may

manifest as either bullae or distinct erythematous

nodules

Older lesions

Cutaneous Vasculitis- Often seen associated with

palpable purpura, and a livid erythematous halo ,

can appear as nodules, bullae or skininfarction,

leading to ulceration which can contain necrotic

tissue. These are also highly painful and have

multiple sites, with unusual shapes and

configurations.

3 types of malignant wounds can occur on the

legs: Squamous cell basal cell carcinom and

malignant melanoma. Of these, squamous can

occur within a chronic non-healing ulcer

(Marjolin’s ulcer) or at the margins of a previously

grafted site, and appear as raised or thickened

edges.

Squamous cell Marjolin’s Ulcer

Necrobiosis Lipoidica Diabeticorum -Lesions

appear as well-circumscribed, erythematous

plaques, with a depressed, waxy yellow atrophic

centre, often in the pre-tibial area. They can also

be described as slightly raised shiny red-brown

patches occurring on the lower legs .

Pyoderma Gangrenosum – Lesions are red, tender

nodules/ pustules, bluish undermined edges when

ulceration occurs; edges may appear “moth-

eaten” and can be exquisitely painful.

l. Circulation: Pulse assessment



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Check the pulse of the dorsalis pedis, palpable at the prominent arch of the

top of the foot between the first and second metatarsal bones. It can be felt

in approximately 90% of people.

Image obtained from Google Images

http://sydney.edu.au/medicine/diabetes/foot/Fexam1.html

Check the pulse of the post-tibial by placing your index finger at the inferior,

posterior edge of the medial ankle. Place your middle and ring finger in a line

between this point and the heel of the foot.

Image from Google Images

http://sydney.edu.au/medicine/diabetes/foot/IMAGES/posteruir%20tibial.jpg

m. Vascular Assessment including ABPI—

To be completed by Wound Care Specialist

(WCS)/Enterostomal Therapy Nurse (ETN) or in

the Vascular/ Diagnostic Imaging Lab

Have client avoid smoking or any caffeine drinks

for ½ hour prior to having ABPI or TBPI performed

(they can both increase the pressure).

n. Toe Brachial Pressure Indexes: Calcification of the arteries can occur in people with diabetes,

advanced age, longstanding hypertension, or renal disease, and can lead to incompressible arteries in

the ankle. This means that you cannot get a systolic reading when taking the blood pressure in the leg

because you cannot obliterate the sound of the pulse. This makes ankle pressures impossible to

measure accurately by traditional techniques. Because calcification occurs less commonly in digital

arteries, a TBPI is a more reliable indicator of peripheral arterial disease than an ankle brachial index.

However, occlusion of the digital artery can occur in the tip of the toe, and would not be apparent when

the toe pressure is taking proximal to this. Toe pressures are generally performed in a vascular or

diagnostic imaging laboratory with equipment that can show the waveforms (monophasic, biphasic or

triphasic) as well as the audible pressures.

o. INTERPRETATION OF ABPI &/OR TOE BRACHIAL PRESSURES AND LOWER LEG ASSESSMENT

FINDINGS

p. Summary

• Summarize your findings

• Describe the type of wound

• Check off the box that describes the wound



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• Summarize the Interdisciplinary interventions that are recommended (based on Section B.2, B.3)

Literature References :

Armstrong, D.G., Lavery, L.A., & Harkless, L.B. (1998). Diabetic Foot Ulcers: Prevention,

Diagnosis and Classification American Academy of Family Physicians. March 15, 1998.

Available at: http://www.aafp.org/afp/980315ap/armstron.html Accessed Aug. 23, 2010.

Botros, M., Goettl, K., Parsons, L., Menzildzic, S., Morin, C., Smith, T., Hoar, A., Nesbeth, H.,

McGrath, & Best, S. (Update: 2010) Practice Recommendations for the Prevention, Diagnosis

and Treatment of Diabetic Foot Ulcers: Update 2010. Wound Care Canada 8(4): 6-40.

Coutts et al. (2007). RNAO Assessment and Management of Venous Leg Ulcers Guideline

supplement.

Dissemond, J., Körber,A. & Grabbe, S. Differential diagnosis of leg ulcers Journal der Deutschen

Dermatologischen Gesellschaft 2006 4:627–634.

Gorst, R. Bagg, G., Albert, M., Shier,B. The Interdisciplinary Lower Leg Assessment Form: The

Evolution of a Clinical Assessment Tool Wound Care Canada 2006 4(3): 30-50. Available at:

http://www.cawc.net/images/uploads/wcc/4-3-gorst.pdf

Hess, C.T. (2010). Venous ulcer checklist. Advances in Skin and Wound Care. 23(8):384.

International Society of Lymphology (ISL) Lymphoedema Staging: (From International

Consensus Document Best Practices for the Management of Lymphoedema available at:

http://www.lympho.org/mod_turbolead/upload/file/Lympho/Best_practice_20_July.pdf

Moloney, M.C., & Grace, P. Understanding the underlying causes of chronic leg ulceration. JWC

13(6): 215-218.

Patel, K., Grey, J.E., & Harding, K.G. (2006). Abc Of Wound Healing: Uncommon Causes Of

Ulceration BMJ: British Medical Journal, Vol. 332, No. 7541 (Mar. 11, 2006), 594-596.

Peters, E.J.G., & Lavery, L.A. (1998). Effectiveness of the Diabetic Foot Risk Classification System

of the International Working Group on the Diabetic Foot. Diabetes Care 21 (5): 1442-1447.

Vowden, P., & Vowden, K., (2001). Doppler assessment and ABPI: Interpretation in the

management of the leg ulceration. Worldwide wounds. Available at: http://www.worldwidewounds.com/2001/march/Vowden/Doppler-assessment-and-ABPI.html



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Suzuki, K. (2007). How to diagnose Peripheral Arterial Disease. Podiatry Today 20(4) Available

at: http://www.podiatrytoday.com/article/6952, accessed June 13, 2010

Documents

South West Regional Wound Care Toolkit - Healthline · South West Regional Wound Care Toolkit ... to identify and document ... Pitting edema can be demonstrated by