Lower Extremity Wounds
Objectives
• Differentiate between arterial, venous, and
diabetic wounds
• Illustrate wound treatment techniques for
lymphedema, venous, arterial, and diabetic
wounds
Epidemiology
Sen et al; 2009
• 17.9 million people in the US have been
diagnosed with diabetes
– 25% of this population will develop ulcers
– 12% of those ulcers result in amputation
• 1.69% of the US population has venous
wounds
Arterial Wounds
Examination
• History of arterial disease
• Blood flow to the extremity
– Pedal pulses (many times unable to locate)
– Ankle Brachial Index (ABI)
• Note edema
• Skin changes: decreased hair, shiny skin, dark
color, decreased temperature, decreased muscle
bulk
• Gangrene of toes
• Nail changes
Arterial Wound Characteristics
• Usually associated with cardiovascular/arterial
disease
• Appearance: Deep wounds, “punched out”,
irregular boarders, may have darker coloring of
tissue, dry, may have edema
• Location: Anywhere the artery is occluded, more
likely to be distal (foot) and lateral leg
• Pain: Elevation of the legs, walking, sometimes at
rest; relieved by dependent positioning
Basic Treatment
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Keeping the wound clean and dry
Preventing infection and trauma
Keep the leg(s) in a dependent position
Create moisture with dressings
Passive exercises
Increase temperature
Avoid constricting socks, clothing
Good nutrition
Other Treatments
• Wounds are very slow to heal
• Medications to increase blood flow
• Surgical:
– Revascularization
– Amputation
Diabetic Wounds
Examination
• Medical history of diabetes
• Check sensation
– Monofilament test for protective sensation
• Check blood flow to the area
– Pedal pulses (may not be present)
– Ankle Bracial Index (ABI)
• Note surrounding skin (callous formation)
• Note foot deformaties
Diabetic Wounds
• Diabetes effects multiple body systems. May see a mixed
wound
• Associated with diabetic neuropathy – where nerves are
affected
• Foot deformities are common
• Usually caused by several factors:
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Decreased sensation
Arterial insufficiency
Unable to monitor feet
Competition for time and resources with other associated
illnesses
– Denial
– Mis-information
Common Foot Deformities Seen With
Neuropathy
• Charcot Foot
Diabetic Wound Characteristics
• Appearance: Round or elliptical, may see a
callous on surrounding tissue
• Location: Areas of pressure or shearing forces,
primarily below the ankle
• Pain: May not have any primarily due to
decreased sensation
Basic Treatment
• Off loading (removing the pressure to the
wound area)
– Using assistive devices to walk
– Transfer to wheelchair only
Important to monitor weight bearing
Balance deficits may increase
• Use specialized foot wear at all times
• Monitor skin of other areas of the foot
Easily become infected
Types of Off Loading
• Shoes
• Splints
Skin Care Guidelines
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Keep feet dry
Pay close attention to between the toes
Diabetic socks
Management of fungal infections of toes and
toenails
• Use pH balanced lotions to keep leg and
periwound skin healthy
• Avoid soaking
Other treatments
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Improved control of diabetes
Debridement – removal of dead tissue
Dressings
Casting
Management of infection
Hyperbaric oxygen (HBO)
Increasing vascularization /medical management
Amputation
Signs and Symptoms of Infection
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Very similar to inflammation
Increased temperature
Increased pain
Purulent drainage (contains pus)
LOOK FOR CHANGES
Venous Wounds
Examination
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Pulses should be present
Look for edema, varicose veins
Note type and amount drainage
Signs and symptoms of infection
Venous Wound Characteristics
• Appearance: Leg may have edema, vericose veins, and
hemosideran staining.
– Wound looks “healthy”(beefy, red), may have excessive
moisture, shiny, irregular boarders of wound
– Surrounding skin may be macerated, crusting, scaling (dry
appearance)
• Location: “Gaiter” area of the lower leg, primarily near the
medial malleolus
• Pain: Sometime, dull, aching. Should be relieved by
elevation/rest.
Many patients with venous hypertension/varicose veins will
also have arterial problems. Wounds may be mixed.
Basic Treatment
• Dressings that focus on controlling drainage
May need frequent dressing changes
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Protecting periwound
Leg elevation
Compression
Walking with compression
Lymphedema
Lymphedema Defined
• Accumulation of lymphatic fluid in the interstitial
tissue
• Different from venous insufficiency because there
is damage to the lymphatic system
• Untreated venous insufficiency can lead to
lymphedema
• Causes: Primary – present at birth or onset at
puberty, adulthood (unknown cause)
• Secondary (most common) – surgery especially
when lymph nodes removed, radiation, trauma,
infection
Lymphedema Characteristics
• Appearance:
– Swelling usually begins distally and will appear worse
distally.
– One limb will be larger than the other.
– Dorsal hump
– Pitting edema in earlier stages. Left untreated, skin will
become hard, fibrous with brown staining
• Location: Extremities but at times in the face and trunk
• Pain: Not usually present but high risk for infection
(cellulitis). Normally will start by the extremity feeling
heavy.
Venous
Insufficiency
Lymphedema
Treatment
• Best treated by Certified Lymphedema Therapists
• Complete decongestive therapy
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Compression
Manual lymph drainage (MLD)
Exercises
Skin/nail care
Patients with lymphedema must always wear
compression garments
Compression
Common Types:
• Compression garmets (stockings)
• Lymphedema wraps (short stretch bandages)
• Ace bandages (long stretch bandages)
• Compression pumps
• Unna’s boots
• Other compression systems
Contraindications for Compression
Therapy
Absolute Contraindications
• Ruling out arterial insufficiency is important
• ABI <0.8
• Suspected/untreated DVT
• Phlebitis
Relative Contraindications
• CHF
• Pulmonary edema
• Kidney failure
• Decreased sensation