Leg Ulcers: Part One – Assessment
July 2013
An overview of best practice
ACC Review 52
This article summarises current best practice for leg ulcer assessment.
• A leg ulcer is defined as the loss of skin, anywhere below
the knee, which takes more than four weeks to heal.
prescribed and non-prescribed medications, smoking,
nutrition, psychological issues and other factors that
may affect healing.
• Determining ulcer aetiology is essential before starting
compression therapy.
Particular risk factors for venous ulcers: Previous
or current deep vein thrombosis, varicose veins,
immobility, reduced calf muscle pump function,
obesity, minor level of trauma, recurrent ulcer, lower
leg trauma, and surgery or fracture.
• Ankle Brachial Pressure Index (ABPI) helps assess
arterial disease severity.
Particular risk factors for arterial ulcers: Smoking,
hyperlipidemia, ischaemic heart disease, stroke,
hypertension and diabetes.
• Ongoing ulcer assessment is necessary to monitor
progress and recognise any factors impeding healing.
Clinical examination
• Two-thirds of leg ulcers are venous in origin.
Aetiology
Accurate diagnosis of ulcer aetiology is essential to
avoid harm from inappropriate treatment1.
Leg ulceration most commonly follows a minor injury
in association with:
• chronic venous insufficiency (45-80%)
General, including taking blood pressure.
A nutritional assessment may include weight and/or
BMI, food and fluid intake, hair and skin changes.
Limb assessment
Both lower limbs should be included in the assessment.
The ankle and knee joints should be assessed for
mobility. Fixed joints can reduce the foot/calf muscle
pump action, reducing venous return.
• diabetes (15-25%)
Venous disease can be assessed using the CEAP
clinical classification tool based on signs of venous
hypertension:
• hypertension2.
C0 no signs of venous disease
Most ulcers are associated with venous disease. Less
common causes or contributory factors include diabetes,
neuropathy, skin cancer, trauma, blood disorders,
vasculitis, immobility and infectious diseases.
C1 telangiectasias or reticular veins
Diagnosis
C4b lipodermatosclerosis or atrophie blanche
Clinical history
C6 active venous leg ulcer1, 3.
The patient should be asked how the ulcer began,
how it has progressed, and how it is affecting
them (including a pain assessment). Past ulcer and
treatment history is important.
Arterial ulcers are usually found on feet, heels and
toes. Signs of peripheral arterial disease include
atrophic shiny skin, pale and cool feet on elevation,
venous guttering, hair loss and nail thickening.
The detection of underlying joint problems and
neuropathy is essential.
• chronic arterial insufficiency (5-20%)
General and particular risk factors should be noted,
including past and concurrent medical conditions,
C2 varicose veins
C3 presence of oedema
C4a eczema or pigmentation
C5 evidence of a healed venous leg ulcer
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Ulcer assessment
Ulcer assessment will help determine the underlying
aetiology and factors that may have a detrimental effect
on healing.
Venous ulcers are relatively painless, unless infected, and
often associated with swelling.
Arterial ulcers are frequently painful, with borders of
lesions appearing as “punched out”4.
Measuring the ulcer provides a baseline to compare
progress. Ruler measurements of width, length and
depth, digital images or tracing onto transparencies are
useful methods. Wound assessment using the “TIME”
acronym is helpful: T – appearance of tissue in the ulcer
bed, I – signs of infection and inflammation, M – moisture
level, type and colour of exudate, E – the condition of the
wound edges and signs of epithelialisation.
Investigations
Blood screen
May include blood glucose, haemoglobin, urea and
electrolytes, serum albumin, lipids, rheumatoid factor,
auto antibodies, white blood cell count, erythrocyte
sedimentation rate, C-reactive protein and liver
function tests.
Bacterial swabs
Should not be taken routinely and only where clinical
signs of infection are present, so to assist in determining
appropriate sensitivities to antibiotics.
Biopsy of the ulcer
May be required if malignancy or vasculitis are suspected.
Ankle Brachial Pressure Index (ABPI)
Using Doppler ultrasound determines the level of arterial
blood flow to the lower limb. The systolic blood pressures
are recorded in the arms and ankles. A calculation is used
to determine the ratio of blood flow. An ABPI of 0.8 to 1.2
indicates good arterial flow; readings of <0.8 are suggestive
of arterial disease and patients with such readings should
not have high compression (40 mmHg) applied to their leg.
Patients with an ABPI reading between 0.6 and 0.8 may be
suitable for reduced compression. Readings of >1.2 suggest
possible arterial wall calcification and therefore ABPI
readings are considered unreliable.
Duplex ultrasound
Is a non-invasive ultrasound scan to investigate venous
or arterial blood flow in the lower legs; it can identify
either arterial obstruction or incompetent veins.
Reassessment
Reassessment should be carried out regularly to monitor
progress and ensure healing is progressing within the
expected time frame. Most ulcers should decrease by 25%
ACC6672 July 2013 ©ACC 2013
in four weeks and heal within 12 weeks. If this does not
occur, referral to specialist services should be considered.
Criteria for referral to specialist
services
• Uncertain aetiology
• Atypical characteristics
• Suspicion of malignancy
• ABPI < 0.8 or above 1.2
• Correctable superficial venous insufficiency
• Rheumatoid arthritis or other suspected condition
associated with vasculitis
• Dermatitis refractory to topical steroids
• Failure to respond to conventional treatment after
four weeks and/or failure to heal within 12 weeks
• Recurring ulcers
• Antibiotic-resistant infected ulcers
• Ulcers causing uncontrolled pain.
ACC cover
ACC provides cover and entitlements for personal
injury. If a leg ulcer is the consequence of a pre-existing
disease or other underlying condition, rather than the
consequence of personal injury, the patient will not be
entitled to cover from ACC. It is important to consider
the nature and cause of any ongoing problems and
establish a causal link between these and personal injury.
Most injury-related ulcers should have healed by three
months, and any ulcers lasting longer than this should be
considered as possibly no longer related to covered injury.
References
1. Australian and New Zealand Clinical Practice Guideline for Prevention and
Management of Venous Leg Ulcers www.nzwcs.org.nz/publications
2. DermNetNz http://www.dermnetnz.org/site-age-specific/leg-ulcers.html
Accessed 20/05/2013.
3. Eklöf B, Rutherford R, Bergan J et al. Revision of the CEAP classification for
chronic venous disorders: consensus statement. Journal of Vascular Surgery
2004; 40(6):1248–52.
4.National Institute for Health and Care Excellence – Leg Ulcer – venous
http://cks.nice.org.uk/leg-ulcer-venous#!topicsummary. Accessed 01/05/2013.
Endorsed by the New Zealand Venous Leg Ulcer Advisory Panel
on behalf of the New Zealand Wound Care Society.