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Venous Leg Ulcers

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by

Wanda Newton

on 19 November 2013

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Transcript of Venous Leg Ulcers

Venous Leg Ulcers
Introduction
Pain, decreased quality of life
Approximately 16% of the population
Female Predominance; (approx. 62%)
Majority have ulcers > 1 year (54%)
As the population ages, Venous Ulcers are more common
Recurrent ulcers are seen in 72% of the population
*Importance of support or compression therapy for life
Medial aspect of the leg (Gaiter area) in 61%
History of DVT in 37%
History of Varicose Vein Surgery in 37%
History, Diagnosis & Treatment
Pathogenesis
Deep Venous System
Superficial System
Communicating Veins (connect deep to superficial)
In supine pressure in the deep veins is zero
Standing pressure at the foot increases to 80-90 mmHg
Walking contraction of muscle helps the flow to the heart
Venous Hypertension
Damaged or leaky Venous valves or faulty calf muscle pump action (check dorsiflexion) will reduce the fall in Venous Pressure.

The sustained high Venous Pressure is referred to as
Venous Hypertension
.
1. Obtain history to determine the venous characteristics and R/O other diagnoses. Assess pain and identify the systemic and local factors that may impair wound healing.

2. Determine the cause(s) of chronic venous insufficiency (CVI) based on etiology: abnormal valves (reflux), obstruction, or calf muscle pump failure.
Quick reference guide to the 12 recommendations for best practices in the prevention and treatment of VENOUS LEG ULCERS
3. Perform ABI test to help R/O significant arterial disease.
4. High compression bandaging if the ABPI is 0.8 or >.
5. Graduated compression stocking to manage and prevent Venous Leg Edema. Wearing stockings to decrease the frequency of ulcer recurrence is important.
6. Intermittent pneumatic compression therapy and/or elevation of the leg as an added benefit.
Cont.
Cont.
7. Consult PT to maximize activity and mobility. Consider appropriate adjunctive therapies.
8. Assess for infection and treat if indicated.
9. Local wound healing environment: debridement, bacterial balance, and moisture balance. Consider Biological agents.
10. Implement medical therapy if indicated for CVI (superficial and deep thrombosis, woody fibrosis).
Cont.
11. Consider surgical management if significant superficial or perforator vein disease exists in the absence of extensive deep disease.

12. Communicate with the patient, the family, and the caregivers to establish realistic expectations for (non)healing. The presence or absence of a social support system is important.
Venous Hypertension
may be due to 3 causes, either alone or in any combination:

1) Valve Dysfunction; Reflux, deep, perforators, or superficial.
2) Obstruction from either complete or partial blockage of the veins (e.g. DVT)
3) Failure of the calf muscle pump function.


Reasons: decreased activity, paralysis, decreased range of motion in the ankle or ankle deformity.
Clinical History
Predisposing Factors:
Prolonged standing or sitting
Obesity
Multiple pregnancies
History of major leg trauma
Previous DVT
Diagnosis of
Venous Disease
First sign of Venous disease is the presence of a dilated long Saphenous Vein on the medial aspect of the calf.

Pitting edema around the ankle toward the end of the day.

Hemosiderin/Hyperpigmentation around the gaiter area - due to red blood cell leakage.
Cont.
Atrophic blanche-smooth white-ivory

Scale& Erythema - may indicate co-existing Stasis Dermatitis.

In long history will develop "wood" hardness that is non-pitting and sclerotic. Cause a inverted champagne bottle appearance with edema above and below.

Skin may be thin with loss of hair follicles and sweat glands.
Ulcer Appearance
Ulcers primarily situated around the medial Malleolous. Other sites include lower 1/3 of the calf, around the gaiter area.
Venous ulcers typically have a yellow base, but with treatment, evolves into healthy granulation tissue
Seldom black escar.
Shallow (partial thickness)
Irregular Shape
Differential Diagnosis
The absence of signs of ulcer healing in four to twelve weeks despite adequate treatment should alert the clinician to biopsy the edge for unsuspected diagnosis
Arterial
Venous
Mixed Arteriovenous
Lymphadema
Pyoderma Gangrenosum
Vasulitis
Infection
Malignancy
General Treatment
Provided the ABI is greater or equal to 0.8, the cornerstone of Venous ulcer treatment is high compression therapy.
1 Layer
2 Layer
3 Layer
4 Layer
Cont.
All patients should be advised to elevate their legs above the level of their heart while sitting
Local wound care; debridement, moisture balance and bacterial balance
When ankle joint mobility is reduced, physical therapy; (e.g. mobilization, stretching)
Adjunctive therapies
Quiz
7 - The cornerstone of Venous Ulcer treatment is:

a) OFF loading
b) Compression Therapy
c) Diuretics
8 - It is safe to compress a lower extremity if the Ankle Brachial Index (ABI) is at or above:

a) 0.8
b) 0.4
c) 1.0
d) A and C
Full transcript