Leg ulcers Doppler and four layer

Leg Ulcers

Definition

• A leg ulcer is defined as a loss of skin below the knee on the leg or foot, which takes more than 6 weeks to heal. (Dale et al, 1983)

  • This definition is beneficial since it does not assume a specific cause of ulceration.

Factors Associated with Leg Ulceration

• Venous Disease

• Arterial Disease

• Diabetes Mellitus

• Rheumatoid Arthritis

• Blood Disease

  • Sickle Cell Anaemia

• Lymphoedema

• Tumors

Prevalence of Leg Ulcers

• 60-80%: Venous Origin

• 10-30%: Arterial Disease

• 10%: Other Conditions

Causes of Sustained Venous Hypertension

• Superficial Venous Incompetence

  • Varicose Veins

• Deep Venous Incompetence

• Deep Venous Obstruction (rare)

• Previous Deep Vein Thrombosis

• Impaired Calf Muscle Pump Function:

  • Immobility

  • Joint Disease

  • Paralysis

  • Obesity

    • Immobility

    • Femoral Vein Compression

    • High Abdominal Pressures

  • Congestive Cardiac Failure

Patient Assessment

• Accurate assessment is essential for successful treatment.

• Use of Doppler Ultrasound may confirm or exclude the presence of arterial disease.

Rare Causes of Leg Ulceration

• Acute/Chronic Nodules or Pustule Ulcer:

  • Painful

  • Raised Inflamed Border

  • Irregular

  • Undermined

• Pyoderma Gangrenosum

Vasculitis

• Inflammation of blood vessels characterized by:

  • Erythema or Purpura

  • Blisters, Necrosis

  • Multiple Lesions or Solitary Ulcer

  • Painful Sites: Lower legs, shin

Factors Associated with Venous & Arterial Ulcers

• Venous Ulcers:

  • Eczema

  • Staining of Skin

  • Ankle Flare

  • Varicose Veins

  • Oedema

  • Previous DVT

  • History of Pulmonary Emboli

  • Leg Fracture

  • Palpable Foot Pulses

  • History of Varicose Vein Surgery

• Arterial Ulcers:

  • History of Heart Disease

  • History of Stroke or TIA

  • Intermittent Claudication

  • Diabetes & Rheumatoid Arthritis

  • Previous Arterial Surgery

  • Foot Pulses Not Palpable

  • Shiny, Hairless Skin

  • Poor Capillary Filling

  • White, Colourless Leg

  • Cold, Bluish Foot

Management of Venous Ulcers

• Graduated External Compression is vital for treatment.

Compression Treatment

• Sustained graduated compression helps reduce venous stasis and tissue oedema caused by venous hypertension.

• Pressure depends on:

  • Size and shape of the limb

  • Operator technique

  • Performance characteristics of the product

Compression/Bandages

• Optimal compression is around 40 mm Hg at the ankle.

• Proper bandaging application is crucial to avoid pressure ulceration, especially over bony prominences.

Dressing Materials

• Avoid contact sensitivity from materials like wool alcohols, topical antibiotics, parabens, and rubber found in some dressings.

• Commonly used dressings include:

  • Aqualcel/Ag (to absorb exudate),

  • Inadine,

  • Silicone impregnated dressings

Education

• Key areas of education include:

  • Understanding the disease

  • Recurrence management

  • Exercise and leg elevation

  • Improving mobility

  • Reducing obesity

  • Improving nutrition

  • Skin grafting in selected patients

  • Venous surgery in selected patients

  • Skin care to manage dry skin

  • Recognizing when to seek help

Other Therapies and Management

• Total Negative Pressure (TNP)

• Maggots

• Other skin closure methods

• Long-term management strategies:

  • Stockings

  • Surgery

  • Counseling

Colour Duplex Imaging

• Examination is done while standing or sitting with the leg dependent.

• A 4-MHz flat linear array transducer is utilized to assess superficial and deep veins.

• Venous Reflux: Defined as reversal of flow for more than 0.5 seconds on release of a calf squeeze.

Chronic Venous Insufficiency (CVI)

• Controversies exist regarding the best treatment for advanced CVI. Treatments aim to correct hydrostatic and hydrodynamic causes of CVI with a pragmatic approach optimizing venous hypertension correction.

Summary of Key Points

• Correct assessment to ensure accurate diagnosis.

• Education on the condition and management strategies is essential.

• Proper dressing selection and compression bandaging are crucial.

• Involvement of doctors for infection and other therapies when necessary.

• Addressing the psychosocial impact on patients is important.

Barriers to Successful Ulcer Healing

• Dry wound bed or excessive exudation

• Presence of devitalized tissue/slough

• Clinical infection

• Poor blood supply/anaemia

• Poor nutrition

• Venous Hypertension

Wound Cleansing

• Ongoing debate about wound cleaning techniques:

  • Types of antiseptics/antimicrobials

  • Wound materials (gauze vs. cellulose)

  • Soaking vs. flushing, saline vs. tap water

Wound Cleansing Continuation

• To remove excess slough and exudate or dressing material.

• It is accepted practice to warm cleansing fluid as cooler fluids can inhibit healing by delaying cell mitosis.

Doppler Ultrasound and Bandaging Systems

• Helpful resources:

  • Video tutorials on applying compression bandages.

Final Note

• Thank you for listening! Feel free to ask any questions.