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

2. 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

3. Prevalence PVD (peripheral vascular disease) ~ 2 million American
Venous stasis ulcers affects 500, ,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

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

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

6. 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

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

8. 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

9. ANKLE BRACHIAL INDEX

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

11. 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

12. 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

13. 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

14. 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-

15. Neuropathic Ulcers
Monofilament testing

16. 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

17. Pressure Points

18. 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

19. 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.

20. 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)

21. 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

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

23. 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

24. 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

25. 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

26. 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

27. VENOUS LEG ULCERS Management Diagnostic Test Non-Invasive
Capillary Refill- < 3 seconds
Venous Refill- < 20 seconds
ABI – within normal limits ( )
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

28. 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

29. 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

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

31. COMPRESSION THERAPY

32. https://youtu.be/FqKjBE6_0AU

33. Venous
Diabetic
Arterial

34. Shiny
Hairless
Painful
Weeping
Irregular
Insensate

35. Questions?

36. References
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., 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: /WON

37. Breakout for Hands-On
COMPRESSION THERAPY