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Leg ulceration: correct assessment is vital

June E Jones
RGN MSc BA(Hons) NDN DPSN PGDipCertEd
Research Fellow
Health and Community Care Research Unit
University of Liverpool
Clinical Nurse Specialist Leg Ulcers
Southport & Formby PCT
E:jonesje@liv.ac.uk

Leg ulcers cause considerable cost to both the patient(2,3 ) and the health service, estimated at £300-600m, of which nursing time is a major element.(4) Venous disease accounts for 70-75% of ulcers, with the remaining 25-30% consisting of mostly arterial disease, mixed aetiology, neuropathic disease and unusual pathologies such as malignancy.(5,6) They affect 1.5-3.0 per 1,000 of the adult population in the UK, with the prevalence increasing with age and higher among women.(7,8)

The starting point in any treatment regimen should be a thorough and systematic assessment to determine the underlying pathology. This means a full clinical history, physical examination, appropriate tests and haemo­dynamic assessment; it is only then that an appropriate treatment plan can be formulated with the patient.(9-11) A visual assessment alone cannot diagnose a leg ulcer;(12) likewise an assessment without Doppler studies is potentially hazardous.(13,14) The assessment should also identify any psychological or social factors that could impact on treatment, concordance and quality of life,(15) together with the patient's understanding of the disease process.

Assessment should always begin with basic biographical data and details of the patient's general medical condition (Table 1) and current medication. Next is an assessment of both limbs (irrespective of whether both have ulceration), together with Doppler ultrasound. The final stage is an examination of the ulcer itself.

[[NIP09_table1_64]]

General patient assessment
Age: The prevalence of ulceration, intermittent claudication and critical limb ischaemia increases with age.(16)

Gender and parity: Many leg ulcer sufferers are elderly females who may have developed deep vein thrombosis or varicose veins during pregnancy.
 
Occupation (previous occupation): Occupations that involve prolonged standing may also contribute to ulcer pathology due to venous stasis.(17)

Mobility: The level of ankle mobility should be noted, as this can lead to poor utilisation of the calf muscle pump and impede venous return.(18)

Weight and diet: Many leg ulcer sufferers are grossly overweight, reducing mobility and inducing strain on the ulcerated limb.(19) Poor diet can hinder the healing process.(20)

Smoking: This may exacerbate the arterial constriction,(21 ) and will delay wound healing.(22)

Pain: This should include type, duration and severity of pain. Arterial pain tends to be severe and aggravated by walking (claudication) or elevation and often disturbs sleep. Pain associated with venous disease is described as dull, heavy or bursting relieved by elevation.

Vascular assessment
Both limbs should be assessed to establish whether the patient has an adequate blood supply. It is not sufficient to palpate the patient's foot pulses, as this is an unreliable predictor of the presence of arterial disease.(23) The handheld Doppler to record the patient's ankle/brachial pressure index (ABPI) forms the basis of arterial assessment as part of a holistic assessment (see Table 2). It is not a diagnostic tool but helps to screen those patients with any degree of arterial impairment for whom compression therapy would not only be inappropriate but potentially hazardous.

[[NIP09_table2_66]]
 
The ABPI for each leg is calculated by dividing the higher of the ankle pressures by the higher of the two brachial pressures. Service guidelines tend to recommend that a patient with an ABPI

Assessment of the skin
There are clinical signs suggestive of venous and arterial disease (see Table 3), which is why it is necessary to spend time examining both limbs and to carefully record any signs and symptoms (see Figures 1 and 2).

[[NIP09_fig1_66]]

[[NIP09_fig2_66]]

[[NIP09_table3_66]]
 
Assessment of the ulcer
While the site of an ulcer is important, it is not diagnostic and so should be considered with all other available information and not in isolation. To ensure an objective record of progress, documentation should include a record of the ulcer size, site, depth, stage of wound healing, odour, exudate, local pain and a description of the edges.

Treatment options

Venous ulcers
Compression therapy remains the optimum treatment for venous leg ulcers.(24) It reverses venous hypertension, reduces oedema and heals venous ulcers. As compression is palliative, rather than curative, it has to be worn as long as the patient has venous disease.(25) Sustained high-compression therapy provided by multilayer elastic, inelastic or compression hosiery improves ulcers and ultimately provides patients with an improved quality of life.(26) There are three systematic reviews demonstrating the increased healing rates of venous ulcers treated with compression therapy.(27-29) However, there remains insufficient evidence to suggest a difference in benefit in terms of ulcer healing between elastic and inelastic compression therapy.

It is important that the patient (whenever possible) is involved in the decision as to which compression regimen is used. Factors such as footwear, allergies, patient mobility and occupation should be considered to improve patient concordance with the treatment and ultimately heal the ulcer. Table 4 outlines the different compression bandage systems, while Tables 5 and 6 list the advantages and disadvantages of the different regimens.

[[NIP09_table4_67]]

[[NIP09_table5_67]]

[[NIP09_table6_67]]

Multilayer systems/long-stretch bandages
Bandages that contain elastomeric fibres will "give" as the calf muscle expands and contracts, absorbing the muscle energy like a ball being hit into a tennis net.

Short-stretch bandages
These bandages are made of 100% cotton in which the threads have been overtwisted to give an extensibility of approximately 90%. The bandage applies a rigid inelastic cuff around the calf that does not yield when the calf muscle contracts, reflecting the muscle force back into the veins. The tension in the bandage falls when the patient is resting, and therefore the bandage exerts high compression only when the patient is active.

Other treatments
Compression remains the mainstay of treatment for venous ulceration; however, various other interventions include dressings aimed at optimising the wound bed, laser therapy, topical negative pressure and ultrasound used as an adjunct to compression or where compression is contraindicated. However, the evidence for some of these treatment options remains limited.(34) Recalcitrant ulcers "may" benefit from the use of skin substitutes,(35) or the patients may be given oral oxpentifylline (Trental; Borg).(36)

Arterial ulcers
Patients with ulcers due to arterial disease require referral to a vascular consultant for further investigation. This group of patients may be suitable for arterial bypass surgery or angioplasty to widen the narrowed vessel. Patients considered unfit for surgery should be advised on the benefits of exercise to open up the collateral circulation and thus improve the blood supply. Patients with ischaemia must not have compression therapy or high elevation. Use of a light retention bandage is all that is required to hold dressings in place. An appropriate level of analgesia should be obtained.
 
Referral for further investigations
Patients are not always referred appropriately for specialist assessment.(37) Patients who fail to make progress, or whose ulcers rapidly deteriorate, should be referred for specialist opinion as they may require tissue biopsy.(38) Those patients whose ulcers are of nonvenous aetiology (rheumatoid, diabetic, arterial, mixed) should automatically be referred. Many areas now have a clinical nurse specialist in leg ulcers, who is a valuable resource. Local protocols will dictate whether the patient is to be referred to a clinical nurse specialist, a vascular surgeon, dermatologist, diabetologist or other specialist.
 
Conclusion
Leg ulceration is the outward sign of an underlying problem that needs to be identified through a thorough, systematic and accurate assessment. Unless this is accurate and identifies the underlying cause of the ulcer and any local problems at the wound site, it is difficult to formulate a treatment plan. Patients could then be subjected to long periods of inappropriate treatment resulting in an adverse effect on their quality of life. Assessment of leg ulceration should be an ongoing process involving the multidisciplinary team, since the nature of the ulcer can change over time.

References

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  2. Charles H. Venous ulcer repair and quality of life [Unpublished PhD thesis]. London: Brunel University; 2001.
  3. Kunimoto B, et al. Best practices for the prevention and treatment of venous leg ulcers. Ostomy Wound Manage 2001;47(2):34-50.
  4. Bosanquet N. Costs of venous ulcers - from maintenance therapy to investment programs. Phlebology 1992;7:44-6.
  5. Cameron J. Leg ulcers: aetiology and differential diagnosis. Huntingdon: Wound Care Society; 1992.
  6. Collier M. Tissue viability. Leg ulceration: a review of causes and treatment. Nursing Standard 1996;10(31):79-81.
  7. Lees TA, Lambert D. Br J Surg 1992;79:1032-4.
  8. Angle N, Bergan JJ. Chronic venous ulcer. BMJ 1997;314:1019-23.
  9. RCN. Clinical practice guidelines: the management of patients with venous leg ulcers. London: RCN; 1998.
  10. SIGN. The care of patients with chronic leg ulcers. Edinburgh: SIGN; 1998.
  11. Clinical Resource Efficiency Support Team. Guidelines for the ­assessment and management of leg ­ulceration. Belfast: CREST; 1998.
  12. Elliott E, et al. J Wound Care 1996;5(4):173-5.
  13. Vowden KR, et al. J Wound Care 1996;5:125-8.
  14. Stacey MC, et al. Eur Wound Manage Assoc J 2002;2(1):3-7.
  15. Walshe C. Living with a venous leg ulcer: a descriptive study of patients' ­experiences. J Adv Nurs 1995;22:1092-100.
  16. Fowkes FG, et al. Edinburgh Artery Study: prevalence of asymptomatic and ­symptomatic peripheral arterial disease in the general population. Int J Epidemiol 1991;20:384-92.
  17. Morison M, Moffatt C. A colour guide to the assessment and management of leg ulcers. 2nd ed. London: Mosby; 1994.
  18. Alexander CJ. Chair sitting and varicose veins. Lancet 1972;1:822-3.
  19. Callam MJ, Ruckley CV. Chronic venous insufficiency and leg ulcers. In: Ruckley CV, et al, editors.Surgical management of ­vascular disease. Philadelphia: WB Saunders; 1992. p. 1281.
  20. Russell L. The importance of patients' nutritional status in wound healing. Br J Nurs 2001;10(6):S42-9.
  21. Cooke JP, Creager MA. Management of the patient with ­intermittent claudication. Vasc Med Rev 1991;2:19-31.
  22. Siana J, et al. J Wound Care 1992;1(2):37-41.
  23. Moffatt C, O'Hare L. Ankle pulses are not sufficient to detect impaired arterial circulation in patients with leg ulcers. J Wound Care 1995:4(3):134-8.
  24. Ramelet AA. Compression and leg ulcers. In: Gardon-Mollard C, Ramelet AA, editors. Compression therapy. Paris: Masson; 1999.
  25. Nelson EA. J Wound Care 1996;5:415-8.
  26. Stacey M, et al. Compression ­therapy in the treatment of venous leg ulcers. NT Plus 2002;98:36.
  27. Fletcher A, et al. Compression ­therapy for venous leg ulcers. Qual Health Care 1997;6:226-31.
  28. Palfreyman SJ, et al. A systematic review of compression therapy for ­venous leg ulcers. Vasc Med 1998;3:301-13.
  29. Cullum N, et al. Compression for venous leg ulcers. Cochrane Review. Oxford; The Cochrane Library; 2001.
  30. Cameron J, et al. A comparative study of two bandage systems. In: Proceedings of the 3rd European Conference on Advances in Wound Management. London: Macmillan Magazines Ltd; 1994. p. 168-9.
  31. Callam MJ, et al. Lothian and Forth Valley ulcer healing trial. Part 1: elastic versus non-elastic bandaging in the ­treatment of chronic leg ulceration. Phlebology 1992;7:59-61.
  32. Blair SD, et al. BMJ 1988;297:1159-61.
  33. Duby T, et al. A randomised trial in the treatment of venous leg ulcers: comparing short stretch bandages, a four-layer system and a long stretch paste system. Wounds 1993;5:276-9.
  34. Nelson EA, et al. Venous leg ulcers. In: Clinical evidence 7. London: BMJ Publishers; 2002. p. 1806-17.
  35. Falanga V, Sabolinski M. A ­bilayered living skin construct (APLIGRAF) accelerated complete closure of hard-to-heal venous ulcers. Wound Repair Regen 1999;7(4):201-7.
  36. Jull A, et al. Oral pentoxifylline for treatment of venous ulcers. In: The Cochrane Library. Issue 3. Oxford: Update Software; 2000.
  37. RCN Institute. The management of patients with venous ulcers. Clinical practice guidelines. York: RCN Institute; 1998.
  38. Taylor A, et al. The importance of tissue biopsy for non-healing ulcers: In: Leaper D, et al, editors. New approaches to the management of chronic wounds. London: Macmillan; 1997.

Resources
SIGN (Scottish Intercollegiate Guidelines Network)
W:www.sign.ac.uk

Leg Ulcer Forum
W:www.legulcerforum.org

Tissue Viability Society
W:www.tvs.org.uk

Wound Care Society
W:www.woundcaresociety.org