Lower Extremity Wounds

1. Lower Extremity Wounds

2. Objectives • Differentiate between arterial, venous, and diabetic wounds • Illustrate wound treatment techniques for lymphedema, venous, arterial, and diabetic wounds

3. EpidemiologySen 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

4. Arterial Wounds

5. 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

6. 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

8. Basic Treatment • 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

9. Other Treatments • Wounds are very slow to heal • Medications to increase blood flow • Surgical: • Revascularization • Amputation

10. Diabetic Wounds

11. 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

12. 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: • Decreased sensation • Arterial insufficiency • Unable to monitor feet • Competition for time and resources with other associated illnesses • Denial • Mis-information

14. Common Foot Deformities Seen With Neuropathy • Charcot Foot

15. 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

16. 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

17. Types of Off Loading Shoes Splints

18. Skin Care Guidelines • 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

19. Other treatments • Improved control of diabetes • Debridement – removal of dead tissue • Dressings • Casting • Management of infection • Hyperbaric oxygen (HBO) • Increasing vascularization /medical management • Amputation

20. Signs and Symptoms of Infection • Very similar to inflammation • Increased temperature • Increased pain • Purulent drainage (contains pus) LOOK FOR CHANGES

21. Venous Wounds

22. Examination Pulses should be present Look for edema, varicose veins Note type and amount drainage Signs and symptoms of infection

23. 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.

24. Basic Treatment • Dressings that focus on controlling drainage • May need frequent dressing changes • Protecting periwound • Leg elevation • Compression • Walking with compression

25. Lymphedema

26. 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

27. 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.

29. Lymphedema vs. Venous Insufficiency Venous Insufficiency Lymphedema

30. Treatment • Best treated by Certified Lymphedema Therapists • Complete decongestive therapy • Compression • Manual lymph drainage (MLD) • Exercises • Skin/nail care Patients with lymphedema must always wear compression garments

31. Compression Common Types: • Compression garmets (stockings) • Lymphedema wraps (short stretch bandages) • Ace bandages (long stretch bandages) • Compression pumps • Unna’s boots • Other compression systems

32. 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