1. District General Hospital
CHRONIC ULCERS
Dr.D.T.Gunasena
MBBS,MS,FRCS(Edin)
Consultant Surgeon
District General Hospital
Gampaha

2. Affects- 3.6% of older people over 65yrs
->5% in older people over 85yrs
10% of population develops chronic ulcers in the course of lifetime with wound related mortality of 2.5%
1/3 to ½ of Hospitalizations
Do You Know ?
In US
5.7 Million patients
20 Billion Dollars Annual Cost
Neglected Lot

3. Incidence of chronic leg ulcers is rising……
Due to,
Ageing population
Increased Diabetes Mellitus
Obesity
Increased risk factors for Atheroslcerosis-Smoking
-Obesity
-etc…

4. In Sri Lanka………..
Insufficient information on the extent of the problem
Underestimated size and gravity
“Open Minds, Close Wounds”
2nd Meeting of the Asian Wound Healing
Association held in Sept. 2014

5. Understanding of factors contribute to non-healing wounds
Aim
Understanding of factors contribute to non-healing wounds
Appropriate management
Multidisciplinary team approach

6. Overview Types of wounds Wound healing –Phases Chronic Wounds
Identification and classification of chronic wounds
Management of chronic wounds
New advances in management of chronic wounds

7. History Prehistory Ebers Papyrus Circa 1500BC Use of Lint
Animal grease
Honey
Differentiation of Acute and Chronic wounds
Silver to control bodily infections
Galen of Pergamum a Greek Surgeon served Roman Gladiators
Modern Medicine
Ancient Egypt
Greece

8. 19th Century…………… With the advancement of Microbiology
Cellular Pathology
1847-Ignaz Sammelweis(Obstetrician)-Hand washing & cleanliness
1860-Joseph Lister-Carbolic acid(Phenol),45% reduction of mortality
1870-Robert Wood Johnson-Production of gauze & wound dressing treated with iodine
1886-Ernst Von Bergann-Heat sterilization of instruments, aseptic surgey
1898-Paul Leopold Friedrich-Wound excision, reduces infections
2oth Century-Polymer synthetics for wounds
George Winter/Howard Maibach-Moist wound dressing

9. Aim is Healing without complications
Wounds
Acute Wounds
Cuts, Abrasions, Lacerations
Contusions
Puncture
Skin flaps and
Bites
Chronic Wounds
Fail to pass through normal healing process
They passes through the normal healing process readily
Any wound > 3/12 considered a chronic wound
Aim is Healing without complications

10. How do wounds heal Haemostasis Inflammation Proliferation or
Granulation
Remodelling or
Maturation

11. Natural wound healing process

12. Normal Healing Process…

13. Chronic Wounds

14. Chronic Wounds Working Definition – wound lasting >3 months
Normal healing process impaired
Arrest at different levels
Remains at same stage without progressing to wound healing
Often underlying cause remains undetected

15. Neutrophil Immigration
Chronic wounds
The wound healing cascade impairs and arrests at different stages
Hemostasis
CHRONIC WOUND
Platelet Aggregation
Neutrophil Immigration
Monocyte Immigration
Granulation
Re-epithelialization
Wound Closure
Scar Formation
Remodeling
Minutes Hours Days Weeks Months Years
Time

16. Affects every aspect of life………
Debilitating disease
Loss of productivity at home & work place
Financial burden on patient’s family & country’s health care system
Reduces quality of life-Pain
-Foul odour
-Discharges
-Sleep impaired
-Deformity & Disfigurement
-Reduced mobility

17. Factors that impede wound healing
Local factors
Inadequate blood supply
Increased skin tension
Poor surgical apposition
Wound dehiscence
Poor venous drainage
Presence of foreign body and foreign body reactions
Continued presence of micro-organisms & Infection
Excess local mobility, such as over a joint
Systemic factors
Advancing age and general immobility
Obesity
Smoking
Malnutrition
Deficiency of vitamins and trace elements
Systemic malignancy and terminal illness
Chemotherapy and radiotherapy
Immunosuppressant drugs, corticosteroids, anticoagulants
Inherited neutrophil disorders, such as leucocyte adhesion deficiency
Diabetes and CRF

18. Chronic Wounds Pressure Sores(PU) Venous Ulcers(VU)
Diabetic Wounds(DU)
Venous Ulcers(VU)
Pressure Sores(PU)
Arterial Wounds (AU)

19. 1.Diabetic Wounds
In UK ,5-7% of people with Diabetes have diabetic foot ulcers
In Europe, treatment cost of DFUs is 10 billion Euros per year
Globally 370 million have Diabetes
In every 20 second a lower limb is amputated due to DM
Development of an infection in a foot ulcer increase the risk of hospitalization 55.7 times & amputation 155 times
Most of Foot & Leg Amputations are due to Diabetic Wounds
Amputation
Diabetes
Neuropathy
Foot Ulcer
Infection

20. A Growing Epidemic…
The worldwide diabetic population is expected to grow from 171 million to 366 million by 2025
Foot complications are one of the most common complications in diabetic patients
The lifetime risk of a diabetic foot ulcer (DFU) is 15% to 25%
Approximately 15% of DFUs result in amputation

21. Cost of Diabetes and Wound Care
$174 billion: Total costs of diagnosed diabetes in the United States in 20071
$20 billion: Chronic wounds cost health care systems annually2

22. Amputations are a serious predictor of death…

23. Diabetic Wounds
Most of Foot & Leg Amputations are due to Diabetic Wounds
Chronic ulcer in a diabetic patient, not primarily due to other causes
Extrinsic causes: smoking, friction, burn
Intrinsic causes: neuropathy, macrovascular and microvascular disease, immune dysfunction, deformity, reopened previous ulcer

24. Peripheral vascular disease occurs in 11% of diabetic patients
Co-Morbidity in DU
Peripheral vascular disease occurs in 11% of diabetic patients
Peripheral neuropathy occurs in 42% of diabetic patients
PVD is associated with delayed ulcer healing and increased rates of amputation

25. 2.Venous Ulcers
An area of discontinuity of the epidermis, persisting for 4 weeks or more, occurring as a result of venous hypertension and calf muscle pump insufficiency

26. Reflux in deep veins in 50 t0 71%
Venous Ulcers
Recurrence in 57%
Reflux in deep veins in 50 t0 71%
Prior DVT causes 95% of deep vein reflux

27. Diagnosis of Venous Ulcers
Location on the calf
Bronzing (lipodermatosclerosis)
Exclusion of arterial insufficiency by bounding DP pulses, or ABI > 0.8
Tend to be slow-healing (~90% heal by one year), irregular, and associated with edema and sloughing

28. 3.Pressure Sores
Visible evidence of pathological interruption of blood flow to dermal tissues
Chief cause: sustained pressure
Most commonly over sacrum, hip

29. 3.Pressure Sores

30. Pressure Ulcers: What Works
Must relieve pressure or it won’t heal.
Must use moist dressing or it won’t heal.

31. 4.Arterial Ulcers Tend to occur on distal areas
Diminished/absent pulses
Punched-out appearance, or gangrene
Requires either salvage revascularization, or amputation—usually the latter

32. Diagnosis: ABI ABI= LE systolic BP/Brachial art syst BP
ABI < 0.7 abnormal; < 0.4 unlikely to heal
Can perform in FMC
Values: normal; mild; moderate; < 0.4 severe

33. Differential Diagnosis
LOCATION
CAUSE
APPEARANCE
PAIN PU DU
Bony Prom
Callus
Pressure
Neuropathy/trauma
Crater
Borders distinct
Intermittent pain
No or diminished pain, sensation VU AU
Calf/ankle
Distal points
Venous Stasis
Inadequate arterial flow
Irregular
Gangrene
Little pain, intact sensation
Constant pain

34. Management of
Chronic Wounds

35. Patient Centered – dealing with person with a chronic wound
Holistic –Total care -Not only wound itself- need to address patient’s other needs, diseases, and psychosocial wellbeing
Wound Care Plan (WCP)
Inter-disciplinary
Needs Participation of multitude of disciplines
Overall strategy and scope of the treatment plan depends on patient’s condition, prognosis, and reversibility of the wound.

36. Basic elements in wound care plan
Different types of wounds need different management
Cleanse Debris from the Wound
Manage Exudate
Promote Granulation and Epithelialization
Treat Infections
Minimize Discomfort

37. Chronic Wounds Appearance
approach has been criticised for being too simplistic as wound healing is a continuum
and wounds often contain a mixture of tissue types.

38. Wound healing continuum
Wound Healing Continuum (Gray et al. 2005) have
been developed. This tool incorporates intermediate colour combinations
between the four key colours

43. Cleanse Debris from the Wound
Cleansing agents
Flowing Water –Requesting pt to bath before dressing change
Normal Saline
Commercial Cleansers
Hydrogen Peroxide
Povidone iodine
Hypochlorite solution
Sterile vinegar solution
Mechanical Cleansers –Whirl pools
Salt dips
Aims
Reduce bio burden
Reduce dead and dying debris
Clean the wound

44. Care of necrotic wound
As areas of necrosis interfere with healing process, need to remove it through any of the following means
Mechanical Debridement –Wet to dry dressings
Autolytic Debridement- Occlusive dressing and wound exudate will debride by its enzymatic relations
Enzymatic Debridement –By softening slough by using enzymes –Iruxol and Papaya
Bio logical Debridement –Maggots therapy
Surgical Debridement –Surgeons blades

45. Manage Exudates Identify the level of moisture
Manage exudates by dressings
Nature of Exudate
Type of wound
Aim of exudate management
Method /Agent
No exudate
Dry
Keep the base moist
Hydrocolloid agent
Intrasite
Need occlusive and non occlusive dressing
Mild exudate
Moist
Keep the wound moist
Absorb moisture
Moderate
Wet
Keep the wound in moist state by reducing exudate
Absorb moisture Form dressing
Heavy
Wet +++
Absorb

46. Care of granulating wounds
Care of granulation tissue – avoid dry or wet to dry dressings
Prevent over granulation
Prevent infection
Minimal Dressing changes
Exudate management and care of peri-wound area
Skin grafting or skin substitutes

47. Care of infected wounds
Reduce bio burden –Cleansing, reduction of necrotic and sloughy tissue
Local antiseptics – rotational
Local antiseptics- cadexomer iodine, crystalline silver, PHMB
Exudate management
Care of peri-wound area

48. For spreading infection and or evidence of systemic infection
Antibiotics
For spreading infection and or evidence of systemic infection
Take blood cultures
Treated with Broad Spectrum antibiotics intravenously.
Topical antimicrobials - used to reduce wound bio burden (EWMA 2006).

49. Minimize discomfort Pain relief Psychological support
Family education and create conducive environment
Social support

50. Dressings

51. Advanced Treatment Modalities
Ultra Sound Debridement
Negative Pressure Wound Therapy
Growth Factor Therapy
Pulsed Electromagnetic Wound Stimulation
Live Skin Equivalent Grafting
Hyperbaric Oxygen
Maggots Therapy

52. Ultra Sound Debridement

53. Negative Pressure Wound Therapy

54. Growth Factor Therapy
PDGF- based dressing 

55. Pulsed Electromagnetic Wound Stimulation

56. Live Skin Equivalent Grafting

57. Hyperbaric Oxygen

58. Maggots therapy

59. Goals………….. Promote wound healing and achieve cure
Minimize amputations
Prevention of recurrence
Effective education reduces incidence of foot ulceration & amputation by over 50%
Appropriate care planning goals for hospice patients may include:
Preventing complications of the wound, such as infection or odor
Of course, you will work to prevent additional breakdown of the skin
We want to do our best to minimize harmful effects of the wound on the
patient’s overall condition. This would be things like depression, social
isolation or general discomfort.
In many of our hospice patients, we know that promoting wound healing
may be unrealistic. Therefore, let’s take a look at some specific
interventions for wound care that might be more feasible.

60. Thank You
Thank You