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Treatment and management of venous leg ulcers

Maureen Schofield
RGN DipGerontology
Associate Lecturer Centre for Research and Implementation of Clinical Practice
Wolfson Institute of Health Sciences
Thames Valley University
Uxbridge
London
E:maureen_schofield@hotmail.com

In modern times the problem of leg ulceration is still with us. Once affected, patients are likely to experience recurrent episodes of open ulceration between periods of healing, two-thirds of patients treated being likely to have repeated episodes of open wounds,(2) and will be in need of careful follow-up and after care. The demographics of the problem of leg ulceration are also changing. Although age and social conditions may play a part in healing potential, they have been cited as having only little relevance in demography.
The facts remain fairly constant: an estimated 1.5-3 people per 1,000 (healthy) population have open, active leg ulcers, and this prevalence increases with age.(3) However, changing times bring with them other changes. One modern-day phenomenon, especially in inner-city areas, is that of drug addicts, who by constantly injecting into veins seriously compromise their venous system, resulting in ulceration. This represents a possible new group of patients in a so far undiscovered and younger age group - patients who will also need long-term monitoring and support.

Blood drainage from the lower limbs
The most common cause of venous leg ulceration is chronic venous insufficiency (described in the literature as CVI or venous hypertension). This results from the accumulation of venous blood in the lower limbs due to inadequate drainage of the vessels. 
The venous drainage system consists of deep veins (popliteal and femoral), which are responsible for draining venous blood from muscles and other deep structures within the limb. They are assisted by the long and short saphenous veins, which drain the skin and subcutaneous fat. There is also a system of perforating veins, which form canals between the deep and superficial veins, allowing drainage between the two main sets of vessels. Valves within the veins open to allow the passage of blood to the heart and close to prevent backflow. 
However, all of these systems are working against the natural laws of gravity and need some help in assisting the venous blood in its upward flow back to the heart. This help is provided by the calf muscle, which acts as a pump by contracting and expanding, squeezing the blood vessels and assisting in the upward movement of the blood. Impairment to this process results in changes to the status of the blood vessels, leakage of venous blood into the tissues, oedema and the characteristic dark pigmentation and scaling of the skin (lipodermatosclerosis), which is commonly found in association with venous ulceration.(4)
Problems can arise with the veins themselves becoming distorted or varicosed, by damage to the valves or by changes occurring in the endothelial linings of the veins (fibrin cuffs and trapped white cells).(5)

Assessment
Thorough assessment and history-taking is essential before any effective treatment can be planned. Table 1 describes the differential diagnosis of the two most common types of lower limb ulceration.

[[NIP04_table1_78]]

A Doppler assessment of the ankle/brachial pressure index will indicate any arterial deficiency, but care should be taken to ensure that there are no underlying factors that could result in a false high reading.(6)
In addition to assessment of the wound, limb and ankle pressure, a thorough medical history should be taken, as multiple pathology and polypharmacy can be factors in both underlying causation and healing potential (see Figure 1). In a forthcoming study the author and a colleague state the cases for both underlying pathology and polypharmacy as contributing factors in both causation and healing potential.

[[NIP04_fig1_79]]
 
If obesity or oedema is a contributing factor it is essential to monitor the patient's weight/body mass index (BMI) at regular (weekly) intervals. This will indicate the effectiveness of any dietary changes or of diuretic therapy. 
The circumference of the limb should be measured at ankle and midcalf to determine the degree of compression required to be effective.
Monthly tracings of the wound's outline on a clear acetate sheet will enable ongoing assessment of wound area, and if backed up with photographs will also give a good indication of the tissue state of the wound bed. 
Any significant deterioration of the wound should be recorded and the treatment plan changed accordingly. If no measurable progress is indicated within two months of treatment being started, a whole reassessment should be carried out.(7)

Treatment
Once a diagnosis of venous ulceration has been arrived at, the most effective treatment is reversal of venous hypertension by means of compression therapy. This is achieved by either single-layer, multilayer or short-stretch bandages, applied over a suitable primary wound dressing (usually a simple, woven, low-adherent dressing). 
Any compression system that can maintain a compression value of 40mmHg at the ankle may be applied, and there are now many systems available. The Four Layer Bandaging System, pioneered at Charing  Cross Hospital by Christine Moffatt,(8) provides the basis for the systems currently available and comprises four different bandages with various properties:

  • A padding layer that protects bony structures and provides absorption of any exudate.
  • A crepe bandage, the main function of which is to provide a smooth base for the additional ­compression layers.
  • An elastic bandage that provides 23mmHg ­compression at the ankle when applied as ­instructed by the manufacturer.
  • A cohesive bandage that fixes and supports the underlying layers and gives 17mmHg of ­compression at the ankle when applied as ­instructed by the manufacturer.

There are now many variations of this basic treatment, and the properties of each bandage, or combination of bandages, must be taken into account when assessing the degree of compression required by individual patients. Many studies have been undertaken to establish the superiority of one system over another, but the basic evidence appears to show that there is little or nothing to recommend any one system over any other.(9,10) Table 2 shows the classification of compression bandages. Table 3 describes the bandage combinations required in relation to ankle circumference.

[[NIP04_table2_79]]

[[NIP04_table3_79]]

The experienced practitioner may also vary any system by applying the bandages differently, or using different combinations of bandages. A small decrease in compression can be achieved by applying a bandage in a straight spiral overlap as opposed to a figure-of-eight application. This can be useful for patients who complain that the bandaging is too tight. More dramatic changes can be achieved by varying the bandages themselves. Single-layer bandages are now available in both elastic and short- stretch varieties. Again the criteria is the compression achieved at the ankle. Patient preference may play a role here, as obviously fewer layers equal less bulk.
Care should be taken if a short stretch (nonelastic) bandage is chosen and swelling/oedema is present, as these bandages, though extremely effective in reducing oedema, will slip when the limb reduces in size, and will be ineffective or may even create a tourniquet effect.
At each bandage change the skin should be examined and the limb immersed in/washed with warm tap water, and a simple emollient such as aqueous cream applied. Any eczema should be treated with a steroid ointment. After softening any scales of lipoderm-atosclerosis can be gently peeled away using forceps.

Follow-up care
It is very important to follow up all patients with venous leg ulceration as the recurrence rate is so high. Patients should continue to wear bandages for two weeks post-full epithelialisation of the wound, at which time they may progress to prescribed compression hosiery. 
As with bandages, the choice of hosiery is very comprehensive and may be dictated by local availability. A compression stocking has an effective life of three months, so if issued with two (four if the problem is bilateral), a patient will need replacement of the current hosiery and possible remeasurement and reassessment every six months. 
Accurate measurement according to the hosiery supplier's instructions is vital, and the patient should be seen at least once, one week following the supply of hosiery, to ensure that they are managing to apply and remove them and that the fit is correct.

Conclusion
Compression therapy is clearly the most effective treatment choice in the healing of venous leg ulceration. 
Since the pioneering work of Christine Moffatt and the Riverside Clinics in the early nineties, many alternatives to achieving the required compression to reverse venous hypertension have become available. These not only may be confusing in their profusion, but may also be available on local contract only. 
The role of the nurse is to accurately assess the patient's needs, to record all observations, measurements, treatments and progress, and to provide the best treatment available locally to meet these needs.

References

  1. Negus D. Leg ulcers - a practical approach to management. Oxford: Butterworth Heinemann; 1991. p. 3-4.
  2. Morison M, Moffatt C. A colour guide to the management of leg ulcers. 2nd edn. London: Mosby; 1994.
  3. Waters J. Wound care: ulcer update. Nurs Times (Wound Care Suppl) 1998;94(7):80-2.
  4. Coleridge Smith PD. The aetiology and pathophysiology of venous ­insufficiency and leg ulcers. See www.ucl.ac.uk
  5. Bennett GM, Moody M. Wound care for health professionals. London: Chapman and Hall; 1995. p. 89-91.
  6. Schofield M. Limitations of Doppler assessment [Letter]. J Wound Care 1996;5(6).252.
  7. Nelson EA, et al. The management of leg ulcers: update. J Wound Care 1996;5(2):59-67.
  8. Morrell CJ, et al. Cost effectiveness of community leg ulcer clinics: randomised control trial. BMJ 1998;316:1487-91.
  9. Fletcher A, et al. A systematic review of compression treatment for venous ulcers. BMJ 1997;315:576-80.
  10. Cullum N, et al. Compression for venous ulcers (Cochrane Review). In: The Cochrane Library 4. 2001. See www.update-software.com

Resources
The Leg Ulcer Reference (CD-ROM) Available from the Centre for Research and Implementation of Clinical Practice
Wolfson Institute of Health Sciences
Thames Valley University
32-38 Uxbridge Road
London W5 2BS
Tissue Viability Society
E:tvs@dial.pipex.com
W:www.tvs.org.uk
Woundcarenet
W:www.woundcarenet.com
Wound Care Information Guide
W:www.medicaledu.com/default.htm
World Wide Wounds
The online resource for dressing ­materials and practical wound management ­information
W:www.worldwidewounds.com

Further reading
Arthur J, Lewis P. When is reduced-compression bandaging safe and effective?
J Wound Care 2000;9:469-71.
Douglas V. Living with a chronic leg ulcer: an insight into patients' experiences and feelings.
J Wound Care 2001;10:355-60.
Plassman P, Peters JM. Recording wound care effectiveness.
J Tissue Viability 2002;12:24-8.