Wounds
Venous
*most
common
Arterial
Appearance /
Characteristics
-irregular edges
-red or ruddy wound bed
-fibrous yellow or glossy
coating over wound bed
-copius drainage
-on medial malleolus, medial
lower leg, areas of trauma
-edema
-hemosiderin staining
-lipodermatosclerosis
-atrophie blanche (fat
(yellow/white) with RBC
(purple dots))
-firm (indurated)
-ankle flare
-eczema – dermatitis
-palpable pulses
-shallow
-heavily
contaminated/infected
-temp normal to mild
warmth
-usually painless; dec w/
elevation or compression
-regular appearance
-may conform to
precipitating trauma
-pale granulation tissue if
present
-black eschar
-gangrene
-little or no drainage
-distal toes, dorsal foot,
areas of trauma
-thin, shiny, anhydrous skin
-loss of hair growth
-thickened yellow nails
-pale, dusky, cyanotic
-dec or absent pedal pulse
-temp dec
Etiology
Risk Factors
Diagnosis
Treatment
Causes of venous HTN:
-vein dysfunction
-calf mm pump failure
-APCR
-vein dysfunction
-calf mm pump failure
-APCR
-trauma/phlebitis
-previous venous ulcer
-advanced age
-diabetes
-pregnancy
-obesity
-Homan’s Sign
-ABI
-Trendelenburg
-Venous Filling Time
Control Swelling:
-compression
(30-40 mmHg)
-elevate LEs
-exercise
-avoid tight clothing
-vasopneumatic device
(60 mins, 5x/wk. 90 sec
on/ 30 sec off. 40-45
mmHg)
Venous HTN causes
ulcers:
-fibrin cuff theory
-WBC trapping theory
Medical Test:
-venography
*hypoxia 2° venous
HTN
Indications /
Contraindications
C/I:
-arterial insufficiency
(ABI ≤ 0.7)
-acute infection
-pulmonary edema
-CHF
-DVT
-claustrophobia
Protect LEs:
-wear bandages
-do not scratch/rub
-apply lotion
-wear good shoes
-inspect feet
-pulsed lavage &
debridement
Arterial insufficiency:
-arteriosclerosis
-atherosclerosis
-trauma
-acute embolism
-RA and DM
Buerger’s disease
Intermittent
Claudication →
Ischemic Rest Pain →
Ulcer
-hyperlipidemia
-hypercholesterolemia
-smoking
-diabetes
-HTN
-trauma
-advanced age
-Pulses
-ABI
-Segmental
pressure
measurements
-Capillary refill
-Rubor of
dependency
Medical Tests:
-Plethysmography
-Duplex Scanning
-Arteriography
-TCOM
(normal=50mmHg,
Sufficient wound
Protect skin:
-moisturize
-avoid adhesives
-reduce friction btwn toes
-provide padding to
protect ischemic tissues
Address wound bed:
-choose dressing to
moisten wound bed.
-debride necrotic tissue if
appropriate.
Maximize circulation:
-avoid compression
-choose footwear to
C/I:
-if ABI >1.2 in
diabetics, can’t use
ABI.
-modalities no use
with low ABI
-no sharp
debridement on dry,
eschar-covered,
uninfected arterial
ulcers with low ABI
prior to surgical
intervention.
-gangrenous tissue
must be referred
-severe pain; inc w/
elevation
-intermittent claudication
healing in chronic
ischemic ulcers
≥35mmHg,
Unlikely to heal<30
accommodate for
bandages & dec stress to
wound.
-AD to off-load
-dependent leg position
-aerobic exercise
-flexibility (gastrocs)
Pressure
*2nd most
common
Stage 1: non-blanchable
erythema, superficial but
dermis affected, no open
area
Stage 2: partial thickness
involving epidermis and/or
portions of dermis,
superficial ulcer, looks like
abrasion or blister, normal
surrounding skin
Stage 3: full thickness
involving epidermis and
dermis, damage or necrosis
of subcutaneous tissue, may
extend down to but not
through underlying fascia, a
deep crater with or without
undermining, ulcer bed may
be fat, slough, necrosis, or
granulation tissue
Stage 4: full thickness with
extensive destruction, tissue
necrosis, or damage to
muscle, bone, or support
structures (tendon, joint
capsule, etc), often tunneling
or undermining, visible or
palpable bone (ulcers with
Soft tissue injury
caused by unrelieved
pressure over bony
prominence and
resulting in damage to
underlying tissue
Ischemia occurs when
external pressure
exceed capillary
pressure (12-32 mmHg
is enough to occlude
capillaries)
-limited mobility
-PVD
-hip fx
-diabetic neuropathy
-Angioplasty → Stent →
Bypass → Amputation
1. Pressure reduction
2. Cleansing
3. Dressings
4. Debridement
5. Nutrition
6. Modalities
7. Surgical treatment
Pressure, shear,
moisture, friction
Medical:
Surgical V-Y advancement
flap (bring muscle, dermis,
epidermis, and
vascularization along to
cover affected area).
Anytime wound reaches
bone, need to have a flap.
Underlying soft tissue is
more susceptible to
pressure than skin
therefore deeper
tissues are larger than
the superficial
Pressure relief:
-active (air) or reactive
(foam) mattresses
-roho cushion (air)
-jay cushion (gel)
Isch-disch
Sacrum most common,
then heels
visible bone have
osteomyelitis)
Unstageable: ulcer covered
with eschar or slough and
true base cannot be seen
Diabetic
Deep tissue injury: wound
begins in subdermal tissue,
initially purple/blue, leads to
denuding of epidermis and
eschar formation, epidermis
not broken through and is
covering necrotic tissue
Neuropathic with intact
circulation: beneath 1st and
2nd metatarsal heads, great
toe, dorsal toes, plaque of
callus, autolytic wound (skin
break-down)
Ischemic with
(neuroischemic) or without
neuropathy: occurs in same
places (margins of foot and
heel), absence of foot pulse,
frequent sepsis, pink,
painful, pulseless, cold foot,
microangiopathy
Critically ischemic with
neuropathy: ABI <.3
Grades:
0 = intact skin
1 = superficial
2 = deep
3 = deep & infected
4 = partial foot gangrene
5 = full foot gangrene
Neuropathic: Painless
trauma, excessive
planar pressures during
walking, mechanical
pressure or shear
stress, foot deformities
(hammer toes), charcot
foot, env around foot
(tight shoes)
Increased prevalence of
medial calcific stenosis
(calcification of tunica
media and basement
membrane)
Microvascular disease
Sustained
hyperglycemia
(decreases all 3 phases
of wound healing, dec
collagen synthesis,
angiogenesis, fibroblast
proliferation, reduce
tensile strength of
wounds, impairs ability
to fight infection)
Nylon filaments at
10-g bending forceif unable to
perceive, loss of
protective
sensation and inc
risk of ulceration
-debridement
-wound care
-off-loading: DonJoy
walking boot (cam walker)
Reduce WB stresses
(plantar ulcers)
-crutches or walker (PWB)
-gait training (dec step
length to reduce forefoot
pressure)
-walking casts (dec
pressure, dec edema,
protect from re-injury)
Total contact cast:
minimize risk of secondary
infection
Stretch Achilles tendon or
heel cord release
C/I for walking cast:
infected ulcers
(Caution: mod-severe
edema, fragile
atrophic skin, deep
ulceration)
C/I for total contact
cast: grades 3-5,
fluctuating edema,
active infection, ABI
<0.45