LEG ULCERATION. BY Helen Langthorne And Emma Rayner

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1 LEG ULCERATION BY Helen Langthorne And Emma Rayner

2 Definition A leg ulcer is a loss of skin below the knee on the leg or foot which takes more than six weeks to heal (CKS 2012). Venous ulcer account for approx 70% Arterial (or ischeamic ulcers) refer to a failure of the arterial system to supply sufficient blood to the limb, causing oxygen and nutrient deficit. This is normally caused by stenosis or occlusion (embolus) of the microcirculation. Account for 21% Mixed ulcers result from a combination of venous and arterial insufficiency.

3 Session aim Epidemiology Aetiology of venous ulcers Wound types Dressing properties Skin care

4 Epidemiology 1-2% of population will suffer from a leg ulcer at some point in their lives (Moffat, Morison, Franks 2007) 25% of leg ulcers will reoccur within 1 year High prevalence in elderly Most common in women 1:3 Chronic ulceration most prevalent in women aged Elderly patients have 50% increase of ulcers of mixed aetiology.

5 Cost Estimated annual cost of 600 million to NHS High proportion of these costs are community nurse input Cost to patient personal and financial

6 Venous leg ulcers Caused by venous hypertension resulting in: Damaged perforator valves- high pressure in dermal capillary bed- damage to microcirculation

7 Causes of venous hypertension Obstruction DVT Incompetent Valves Varicose veins Paralysis Immobility Calf muscle pump failure.

8 Predisposing factors- venous Previous ulcer Phlebitis Injury DVT Fracture Vein surgery Joint surgery Cellulitis

9 Muscular Activity: The Skeletal Muscle Pump 1) Muscle contracts 2) Blood forced toward the heart 3) Blood does not flow backwards 2 Proximal valve open 1 Pressure (vein) 3 Vein Distal valve closed SV Regulation: EDV: Skeletal Muscle Pump

10 Muscular Activity: The Skeletal Muscle Pump 1) Muscle relaxes 2) Blood moves into the vein 3) Blood does not flow backward from the heart 1 3 Proximal valve closed Vein Pressure (vein) 2 Distal valve open SV Regulation: EDV: Skeletal Muscle Pump

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13 Venous ulceration skin changes Capillary permeability partly responsible Lipodermatosclerosis -woodiness, laying down of fibrous tissue. Champagne leg. Atrophe blanche- areas of white tissue, avascular areas of scar tissue Ankle flare- very small dilated blood vessels. Haemosiderin brown staining caused by leakage of blood cells. Irritation of skin and eczema due to breakdown of products of haemoglobin.

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18 Other signs of venous ulcers Ulcer in gaiter region-lower third of leg most common site medial malleolus Ulcers tend to be shallow and well vascularised Ankle oedema Normal pedal pulses Aching heavy legs-constant discomfort Loss of calf muscle

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20 Effects of compression therapy in venous ulceration Reduction of venous reflux Valvular incompetence corrected Venous return improved Capillary distension and white cell trapping reduced Absorption of extracellular fluid promoted Hypoxia caused by high venous pressure reduced.

21 Types of compression 4 layer bandage, gives up to 40mmHg at ankle. Short stretch bandaging gives up to 40mmHg at ankle (higher working pressure, lower resting) Hosiery kits giving 40mmHg at ankle Class 1 hosiery gives 14-17mmHg British Standard, European mmhg Class2 gives 18-24mmHg BS, European gives 23-32mmHg Class mmhg BS and European gives 34-46mmHg Juxta cures leg wrap (variable compression)

22 THE WOUND VENOUS ULCERS ARTERIAL ULCERS SIZE Large often more than 10cmsq Small SHAPE Irregular saucer profile Deep punched out, cliff edges SITE OEDEMA Over medial gaiter region of leg Associated with limb oedema Usually over toes, foot, ankle, any bony prominence Oedema not common PAIN Painful but can usually be controlled Worse on elevation or exercise. Night pain, relieved by hanging leg out of bed EXUDATE Frequently heavy Normally dry ( unless infected)

23 COMMON SITES VENOUS & ARTERIAL ULCERATION

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29 Other causes of ulceration Neuropathy associated with diabetes mellitus, spina bifida, leprosy Vasculitic ulcers in patients with polyarteritis nodosa and systemic lupus erythematosus Rheumatoid- 10% of patients will develop and ulcer at some time. Infection TB, leprosy, syphilis, fungal infection.

30 ANKLE BRACHIAL PRESSURE INDEX Rest patient prior to test in horizontal position Check pulses on both arms and at least 2 pulses on both legs Take highest reading and divide ankle by brachial

31 ABPI Measurement

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33 INTERPRETATION OF RESULTS ABPI Index Severity of disease 0.8 or over Minimal damage to the arterial circulation Arterial damage - mild to moderate Below 0.6 Below 0.4 Over 1.2 Major failings in arterial circulation (consider Vascular referral) Severe arterial damage limb at risk Unable to occlude arteries, possibly due to calcification of vessels

34 Mixed Aetiology Definition An ulcer of both venous and arterial aetiology insufficiency % of ulcers do not fall easily into venous or arterial category

35 Patients with mixed venous and arterial aetiology care must be taken to assess the degree of the ischaemia before any decision regarding the management of ulcers with an arterial component can be made (Cameron 1991).

36 Other causes cont Metabolic- pyoderma gangrenosum, characterised by deep purple margins, usually associated with RA, Chrohns disease and ulcerative colitis Lymphodema Trauma Iatrogenic- too tight bandaging Malignancy

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45 NECROTIC Tissue that is deprived of oxygen and nutrients Black, leathery (necrotic) appearance when exposed to air Or yellow/grey (slough) appearance when moist

46 Necrotic

47 SLOUGH Yellow in colour Favourable environment for the growth of bacterial organisms. (Bowler et el 2001) May impair the wound repair process

48 Sloughy Tissue

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50 GRANULATION TISSUE Red colour Proliferation phase of wound healing Growth of capillaries, arterioles, venules and a network of collagen in the surface of an open wound. Tops of capillary loop give granular appearance

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53 Epithelialisation Pale pink/bluey-pink at wound edges Slightly raised wound margins Islets of epithelium shallow wounds with large surface area

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56 INFECTION One of the most significant factors which can delay wound healing Cellulitis, discharge, discolouration Friable bleeding granulation tissue Pain, tenderness Odour Pocketing, bridging at the base of wound Wound breakdown

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58 Hydrogels Amorphous gels or sheets Gels contain approx 78% water Rehydrate eschar and debride sloughy wounds (USE WITH CAUTION ON DIABETIC OR ARTERIAL ULCERS) Require secondary dressing Can macerate surrounding skin Beware will kill larvae E.g Intrasite Gel.

59 Hydrocolloids Developed from stoma products, Occlusive dressing Contains mixture of pectins, gelatines, sodium carboxymethylcellulose & elastomers Encourages autolysis of necrotic & sloughy wounds Interacts with exudate, producing a distinctive, odourous fluid that bathes the wound bed E.g Granuflex, Duoderm

60 Non-Adherent dressings Primary dressing used for ease of removal due to its low adherent properties Has no absorbent capacity Most are silicone coated Exudate passes through dressing to secondary dressing E.g NA Ultra, Silflex, Mepitel.

61 Larvae Involves the use of larvae of the greenbottle fly. Introduced in either T-bags or free range to debride necrotic, sloughy and/or infected tissue. Release chemicals into the wound that break down dead tissue into a liquid that they then remove and digest. Takes 3-5 days Usually only one application is needed.

62 Hydrofibre Fibrous material made of cellulose sheet or ribbon Forms a gel when in contact with exudate Retains high amount of exudate Non adherent and removes slough E.g Aquacel, Durafibre

63 Antimicrobials Lower the bacterial bioburden of the wound Only treat the wound surface Providone iodine = inadine, betadine gradually release iodine (inadine released within hours) Cadexomer iodine (Iodaflex, Iodasorb) = elemental iodine released on exposure to exudate (3 days effect) Silvers : Aquacel Ag, Urgotull SSD, Acticoat.

64 Foam Dressings Multiple layers of hydropolymer or hydrocellular foam Absorbs several times own weight in exudate N/A wound contact layer, vapour permiable outer layer Come as non-adhesive, adhesive, shaped and cavity dressings. Can be left insitu for up to five days depending on exudate E.g Allevyn, Advasorb, Biatain, Activheal,

65 Alginates Seaweed based Highly absorbent it absorbs 13 times own weight of exudate Use on moderate exuding wounds Alginates contain calcium ions, exchange with sodium ions in the blood to initiate the clotting cascade E.g Kaltostat, Sorbsan

66 Super absorbants For use on moderate to highly exudating wounds to absorb and retain fluid Reduces risk of leakage Minimises maceration Many available Most have stay dry technology I.e.: Eclypse, Zetuvit, Flivasorb, Sorbion, xupad

67 Skin Care Wash the leg in a lined bucket, change water and liner for each leg, or let patient shower using soap substitutes Carefully pat dry, pay attention to inbetween toes, check for Tinea Pedis Moisturise well, in downward motion to prevent folliculitis, if possible advise patient to apply frequently Treat any Eczema

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