Leg ulcers can be defined as loss of skin in areas below the knee (on the leg or foot) which take longer than 6 weeks to heal.
Factors Related To Leg Ulcers
- venous disease (60-80% of all leg ulcers are of venous origin) – conditions that damage the veins eg. blood clots, deep vein thrombosis, phlebitis, varicose veins, spider veins, and chronic venous insufficiency.
- arterial disease (10-30% of all leg ulcers are of arterial origin) – a.k.a. artery disease is a vascular disease affecting the body’s arteries.
- diabetes mellitus – metabolic diseases characterised by hyperglycaemia due to problems with insulin secretion, insulin action, or both.
- rheumatoid arthritis – an autoimmune inflammatory disease in which the immune system attacks the body’s healthy cells, leading to inflammation in the affected parts, most commonly the joints.
- sickle cell anaemia – red blood cell disorder, usually inherited, in which there is lack of healthy red blood cells. In normal circumstances, red blood cells are flexible and round, thus can move easily through the blood vessels. In sickle cell anaemia, red blood cells are shaped like sickles or crescent moons.
- lymphoedema – a chronic condition that causes the body’s tissues to swell, most commonly affecting the arms or legs as a result of an inefficient lymphatic system.
- tumors – abnormal mass of tissue resulting from excessive cell division or cells that do not die when they should.
Sustained Venous Hypertension
Sustained Venous Hypertension happens when valves are damaged, leading to increased blood pressure in the leg veins, possibly causing ulcer formation. Sustained Venous Hypertension is caused by:
- Superficial Venous Incompetence – a common condition occurring due to decreased blood flow from the leg veins up to the heart. Lack of adequate blood flow results in blood pooling in the leg veins, leading to conditions such as spider veins, reticular veins and varicose veins.
- Deep Venous Incompetence – a problem with the valves of the veins of the legs, blockage of the veins, or both, leading to leg ulcers, pain and swelling.
- Deep Venous Obstruction – partial or complete occlusion of the lumen leading to decreased blood flow and increased blood pooling (frequently mistaken as DVT – diagnosis requires ultrasound investigation).
- Previous Deep Vein Thrombosis – a medical condition resulting from blood clot formation within a deep vein.
- Impaired Calf Muscle Pump Function – issues related to vein patency, valve competence, and proper calf muscle function.
- Immobility – lack of ability to move freely
- Joint Disease – a common wear and tear disease typically caused by repetitive motions resulting in inflammation and structural joint damage, leading to pain, redness and swelling.
- Paralysis – loss of muscle function resulting from issues with the way messages are passed from the brain to the muscles. Paralysis can be complete or partial, on one or two sides of the body, in one area or widespread.
- Obesity – a complex disease involving excessive amounts of body fat, possibly leading to immobility, femoral vein compression, and high abdominal pressures.
- Congestive Cardiac Failure – heart disease which is caused by the cardiac muscle pumping blood in a less efficient manner than it should.
Chronic Venous Insufficiency
Rare Causes Of Leg Ulcers
Pyoderma Gangrenosum
Vasculitis
Factors Associated With Venous Ulcers VS Arterial Ulcers
VENOUS ULCERS
- eczema
- skin staining
- ankle flare
- varicose veins
- oedema
- leg fracture
- previous deep vein thrombosis
- history of pulmonary embolism
- history of varicose vein surgery
ARTERIAL ULCERS
- intermittent claudication
- diabetes
- rheumatoid arthritis
- previous arterial surgery
- non-palpable foot pulses
- shiny hairless skin
- poor capillary refill
- cold bluish foot
- white colourless leg
- history of heart disease
- history of stroke or transient ischaemic attack
NOTE: patients who complain of not being able to walk for a while without resting, or needing to get out of bed at night to sleep on an armchair sitting down due to pain most probably have arterial ulcers.
Leg Ulcers Assessment and Management
Assessing the patient accurately leads to an accurate diagnosis. This is crucial for leg ulcers healing since different medical supplies are used for different diagnosis.
Investigating a leg ulcer should start by questioning its history – how long has it been there? Is there a pedal pulse present? Absent pedal pulse may indicate arterial deficiency.
A doppler ultrasound, which works like a blood pressure pump, allows correct diagnosis of arterial disease if present.
Graduated external compression is an important factor resulting in the treatment of venous leg ulcers, since such treatment overcomes the effects of venous hypertension by reducing venous stasis and preventing oedema. Compression treatment provides external pressure that counteracts the hydrostatic pressure within the veins whilst standing. The external pressure that compression treatment provides depends on the affected limb’s size and shape, the technique used, and the used product’s characteristics.
Ideally, a compression level of 40 mmHg at the ankle area is recommended to overcome venous hypertension.
Compression therapy should NOT be used for arterial disease!!
Studies have shown that designer dressing materials have no additional effect on wound healing than the healing achieved by the use of simple low adherent dressings covered with multilayer compression bandaging. Commonly used dressings include Aquacel Ag (absorbs and controls exudate), Inadine, and silicone-impregnated dressings.
NOTE: Avoid compression bandaging bony prominences as doing so can easily lead to pressure ulcer formation.
Other Therapies & Management
Total Negative Pressure
Maggot Therapy
Schlerotherapy
Stockings – for long term management
Barriers To Leg Ulcers Healing
- dry wound bed
- wet / highly exuding wound
- slough presence
- infection
- poor nutrition
- anaemia / poor blood supply
- venous hypertension
Leg Ulcers Patient Education
Educate the patient with leg ulcers about:
- the disease
- recurrence and management of leg ulcers
- the importance of exercise
- the effect of obesity on leg ulceration
- how better nutrition promotes better wound healing
- leg elevation
- mobility and its relevance to leg ulcer formation
- skin care, including dry skin care to prevent further skin tissue damage
- available treatments
- when to seek help
NOTE: Patient should be warned that while changes in relation to the above may reduce the probability of leg ulcers to reappear, it may still happen.
Leg Ulcers Nursing Care
- Take detailed history
- Assess wound thoroughly and document all findings
- Make sure the patient receives a correct diagnosis
- Use appropriate dressings and correct compression bandaging
- In case of infection, liaise with medical professionals for possible additional treatment
- Topical antibiotic treatment should be avoided especially due to the problematic antibiotic resistance frequently encountered
- Consider relevant therapies in relation to the patient’s individual needs
- Identify patients in need of medical review
- Refer to specialist professionals if needed in a timely manner
- Be aware of the patient’s psychosocial impact of the wound
- Educate patient
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Claire is keen about public education on health-related subjects as well as holistic patient-centered care. She is also passionate about spreading awareness on the negative effects that domestic abuse leaves on its victims’ mental, emotional, social and physical wellbeing.
Claire aspires to continue studying following completion of her Nursing Degree, because she truly believes in lifelong education.
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