Unwrapping Lower Extremity Ulcers Sharon D. White, BSN,RN,CWOCN University of Alabama - Birmingham

Objectives Identify different types of lower leg ulcers Describe at least 3 major risk factors that may contribute to arterial, venous and diabetic ulcers Identify the characteristics of arterial, venous and diabetic ulcer List at least 2 interventions for treating arterial, venous and diabetic ulcers

Prevalence PVD (peripheral vascular disease) ~ 2 million American Venous stasis ulcers affects 500,000-600,000 people in the US every year. VLU-cost per patient exceeds $40,000 Total estimated cost to the US health care system is > 1 billion per year (Fletcher 2011) Diabetes Mellitus (DM) affects ~25.8 million Americans in 2011 15-25% of DM are at risk for developing foot ulcers $1 in $10 health care dollar in 2010 were attributable to DM (Guffanti 2014) 85% of all non traumatic amputations are diabetics Mortality after an amputation is 40% within the 1st year and 80% within 5 years

Arterial Ulcers Lower Extremity Arterial Disease (LEAD) Atherosclerosis in the older adults Premature atherosclerotic disease or thromboangitis obliterans (Buerger’s Disease)in younger adults

Arterial Ulcers Risk Factors Reversible Irreversible Hypertension (controlled) Diabetes (controlled) Cigarette smoking Obesity Sedentary lifestyle Irreversible Male Strong family history

Arterial Ulcers Assessment Patient history (assessing for risk factors) Pain Location Character Exacerbating and relieving factors Ulcer History Onset Precipitating factors Past and Present treatment Progress/regression

Arterial Ulcers Signs and Symptoms Location Wound Bed Exudate Tips of toes Pressure Points Areas of trauma Wound Bed Exudate Wound Edges

Arterial Ulcers Management Diagnostic test Ankle Brachial Index (ABI) The ankle-brachial index (ABI) is the ratio of the systolic blood pressure (SBP) measured at the ankle to that measured at the brachial artery

ANKLE BRACHIAL INDEX

Arterial Ulcers Surgical Pharmacologic Lifestyle Changes HBOT Bypass Grafts Angioplasty Pharmacologic Antithrombotics Hemorrheologics Analgesics Lifestyle Changes Cessation of Tobacco Use HBOT Topical Therapy

Neuropathic Ulcers Lower Extremity Neuropathic Disease (LEND) LEND is the result of a long history of uncontrolled diabetes Diabetic foot ulcers result from the simultaneous actions of multiple contributing causes. The major underlying causes are noted to be peripheral neuropathy and ischemia from peripheral vascular disease Peripheral neuropathy is a common complication of diabetes, affecting >30% of the diabetic population (1). In the foot, peripheral neuropathy leads to dry skin and loss of the protective sensations of pressure and pain; together with reduced joint mobility (2), it also increases the risk of ulceration induced by unperceived minor injury from shoes and other physical trauma (3). The presence of macrovascular disease, possibly functional microangiopathy (4,5), and infection increases the probability of a foot ulcer leading to a lower-limb amputation (6). Foot ulcers will occur in 5-10% of the diabetic population; up to 3% will have a lower-limb amputation (7). Ulceration is the most common precursor of amputation and has been identified as a component in more than two-thirds of lower-limb amputations (8). The presence or absence of infection and/or ischemia, footwear and pressure relief, and overall glycemic control influence the healing of ulcers (9). The depth of an ulcer is another important factor that

Neuropathic Ulcers Risk Factors Advanced Age Diabetes Hansen’s disease Heredity Smoking HIV/AIDS HTN, Obesity, Raynaud’s disease, scleroderma, hypo/hyperthyroidism, COPD Spinal Cord Injury, orthopedic procedures Malabsorption syndrome due to bariatric surgery, celiac disease History of previous ulcers History of amputation Vascular insufficiency

Neuropathic Ulcers Assessment Common Location Plantar Foot Metatarsal head Dorsal and distal aspects of toes Heels Wound Appearance Pale, pink, necrosis, eschar Size Edges well defined- undermining Shape- round or oblong Exudate- small to moderate- odor

Neuropathic Ulcers Assessment Surrounding Skin Color Fissures, maceration Callus Musculo-skeletal/foot deformities Edema Tempature Tinea pedis Diabetic skin markers Diabetic skin markers Necrobiosis Lipoidica- non scaly plaques Acanthosis Nigricans- dark brown or gray velvety plaques o the skin usually located under the arms, groin, upper thighs, on the neck or near the genitalia Bullosis diabeticorum-

Neuropathic Ulcers Monofilament testing

Neuropathic Ulcers Assessment Nails Dystrophic, hypertrophy, Onychomycosis, paronychia Complications Infection Arterial ischemia Osteomyelitis Charcot fracture Gangrene Pain Perfusion Pain worse at night Decreased or altered sensitivity to touch Pain may be superficial, deep, aching , stabbing, dull, sharp, burning or cool May describe as numbness, tingling, shooting, pins and needles

Pressure Points

University of Texas Wound Classification System of Diabetic Foot Ulcers Grade I-A: non-infected, non-ischemic superficial ulceration Grade I-B: infected, non-ischemic superficial ulceration Grade I-C: ischemic, non-infected superficial ulceration Grade I-D: ischemic and infected superficial ulceration Grade II-A: non-infected, non-ischemic ulcer that penetrates to capsule or bone Grade II-B: infected, non-ischemic ulcer that penetrates to capsule or bone Grade II-C: ischemic, non-infected ulcer that penetrates to capsule or bone Grade II-D: ischemic and infected ulcer that penetrates to capsule or bone Grade III-A: non-infected, non-ischemic ulcer that penetrates to bone or a deep abscess Grade III-B: infected, non-ischemic ulcer that penetrates to bone or a deep abscess Grade III-C: ischemic, non-infected ulcer that penetrates to bone or a deep abscess Grade III-D: ischemic and infected ulcer that penetrates to bone or a deep abscess

Wagner Classification of Diabetic Foot Ulcers Grade 0: No ulcer in a high risk foot. Grade 1: Superficial ulcer involving the full skin thickness but not underlying tissues. Grade 2: Deep ulcer, penetrating down to ligaments and muscle, but no bone involvement or abscess formation. Grade 3: Deep ulcer with cellulitis or abscess formation, often with osteomyelitis. Grade 4: Localized gangrene. Grade 5: Extensive gangrene involving the whole foot.

Neuropathic Ulcers Treatment Improve Tissue Perfusion Prevent Trauma Offload wounds Proper Footwear Use assistive devices for support, balance and additional offloading Pressure redistribution devices while in bed Routine professional nails care- Podiatrist Avoid chemical, thermal, mechanical injury Heating pads Hot soaks Bare feet Wear socks or stockings with shoes- (reduces friction)

Neuropathic Ulcers Treatment Topical Therapy Prevent Trauma Treat Infection Promote wound healing Moist wound healing Debridement Avoid occlusive dressing Adjunctive Therapy HBOT Skin substitutes NPWT Growth factors Surgery to correct deformities

OFF LOADING Diabetic Shoes C.R.O.W. Total Contact Casting CAM Walker

VENOUS LEG ULCERS Lower Extremity Venous Disease (LEVD) Lower extremity venous leg ulcers are caused by chronic venous hypertension. Failure of valves in the veins or faulty calf muscle pump action in the legs results in inadequate fluid return from the legs. Fluid extravasations, tissue ischemia and, eventually, ulceration is the common course of the condition

VENOUS LEG ULCERS Risk Factors Advanced Age Obesity Pregnancy Systemic Inflammation Venous thromboembolism Varicose veins Pulmonary embolus Sedentary lifestyle Trauma/leg fractures Family hx of venous disease Previous wound Injection drug user Impair calf muscle pump Restricted range of motion of the ankle Comorbid conditions CHF, Lymphedema, Orthopedic procedures

VENOUS LEG ULCERS Assessment Location Malleolus Medial aspect of leg superior to medial malleolus Appearance: Wound depth – usually shallow, superficial crater Wound edges – irregular Wound bed – ruddy red yellow adherent or loose slough Amount of exudate – moderate to high Common in the medial but can be anywhere on the lower leg Infection is not common Varies in size

VENOUS LEG ULCERS Assessment Pain – variable; dull aching, heaviness, or cramping Edema – generalized, often worsens during the day Skin Conditions Periwound margin: macerated, crusty Dermatitis – inflammatory process due to extravasation of proteolytic enzymes and metabolic waste into tissues Scaling Hemosiderin staining Fibrotic tissue Atrophe blanche, white, fragile tissue with tiny, tortuous blood vessels Ankle flare Scarring from previous ulcers Dermatitis Itching, weeping, crusting, scaling, erythema Leg pain worsens with leg dependency, elevation relieves the pain

VENOUS LEG ULCERS Management Diagnostic Test Non-Invasive Capillary Refill- < 3 seconds Venous Refill- < 20 seconds ABI – within normal limits (1.0-1.3) Sensory/neuropathy Vascular Studies Venous duplex imaging Doppler Ultrasound Photoplethysmography, Venography Labs The inability to feel the monofilament, diminished vibratory perception and diminished reflexes indicates a loss of protective sensation and an increase risk for wounds

VENOUS LEG ULCERS Debridement Compression Therapy Surgical 30-42 mmHg –ABI > 0.8 23-30 mmHg- ABI < 0.8 Do NOT apply compression if ABI < 0.5 Short stretch bandages (e.g. Setopress, Surepress, Comprilan) Unna’s Boot Multi-layer- 2 or 4 layer wraps Intermittent pneumatic compression Surgical Obliterate damaged vein Subfascial endoscopic perforator surgery (SEPS) Topical Therapy Treat infection Topical steroids Topical emollients Topical analgesics Also control weight , medications,-Trental- Increase exercise- walking Calf muscle exercises, toe lifts, ankle flexion Elevate legs 4 times a day above heart for 30 minutes

VENOUS LEG ULCERS Patient Education Prevention is critical to manage re-occurrence Re-occurrence rates 26% to 69% following ulcer healing* Principles of Venous Leg Ulcer Prevention Wear bandages or stockings Elevate legs for 15+ minutes several times a day Exercise – walk, cycle Avoid standing in one position Don’t wear constricting clothing Protect legs from trauma Pay attention to legs

COMPRESSION THERAPY UNNA’s BOOT 2- LAYER WRAP 4- LAYER WRAP

COMPRESSION THERAPY

https://youtu.be/FqKjBE6_0AU https://youtu.be/l0iuNjZ0SmQ

Venous Diabetic Arterial

Shiny Hairless Painful Weeping Irregular Insensate

Questions?

References http://c.ymcdn.com/sites/www.wocn.org/resource/resmgr/Publications/Ankle_Brachial_Index_Quick_R.pdf http://www.wocn.org/?page=QuickRefGuideLEWound Fletcher, S.,2011. Successful treatment of venous stasis ulcers with combination compression therapy and pulsed radio frequency energy in a patient scheduled for amputation. Journal of Wound, Ostomy, Continence Nursing. 38(1):91-94. Guffanti, A., 2014. Negative pressure wound therapy in the treatment of diabetic foot ulcers: A systematic review of the literature. Journal of Wound, Ostomy, Continence Nursing: May-June (41) 3: 233–237. doi: 10.1097/WON.0000000000000021

Breakout for Hands-On COMPRESSION THERAPY