Characteristics and Identification of Wound Types: Arterial and Venous Insufficiency Ulcers

Original Editor - Stacy Schiurring based on the course by Dana Palmer

Top Contributors - Stacy Schiurring, Jess Bell and Tarina van der Stockt

Introduction

This article provides information for those rehabilitation professionals who are new to wound care or have been away from the practise and need a review of wound type identification. This article will not go into specifics on wound assessment or treatment.

The five most common types of chronic wounds include (1) arterial ulcers, (2) venous insufficiency ulcers or venous wounds, (3) neuropathic wounds, or diabetic foot ulcers (DFUs), (4) pressure injuries, formerly known as pressure ulcers, and (5) non-healing surgical wounds.

The terms ulcer and wound will be used interchangeably throughout this article.

Due to the large amount of information to be presented, this topic has been divided into three separate pages. This page will cover arterial and venous insufficiency ulcers. To learn more about neuropathic wounds, please see this article. To learn more about pressure injuries and non-healing surgical wounds, please see this article.

Arterial Ulcers

Arterial ulcers (ischemic ulcers) are caused by poor tissue profusion to the lower extremities. This impaired blood supply causes nutrient and oxygen deprivation, and results in tissue hypoxia and cell death. This leads to wound formation in the overlying skin and tissues. Additionally, decreased blood supply can impair the body's ability to heal, allowing minor scrapes or cuts to develop into ulcers.

• Arterial wounds account for about 10 to 20% of lower extremity ulcers
• Arterial ulcers are the result of peripheral arterial disease

Peripheral arterial disease

Peripheral arterial disease (PAD) is caused by the narrowing or blockage of the arteries, most commonly caused by atherosclerosis. PAD can occur in any artery but it is more common in the legs than the arms. 40% of people with PAD are asymptomatic, knowing what to look for may save a limb or a life

• PAD occurs along a spectrum and progresses incrementally
• It is asymptomatic until it reaches a threshold where the body is no longer able to compensate for the reduced blood flow, which can be when the artery is 60% or more occluded

ADD s/s of PAD?

PAD Screening

Patients with PAD have a higher risk of asymptomatic coronary artery disease, and are at a greater risk of cardiovascular events. Therefore, it is important for the rehabilitation professional to be able to screen for PAD in the clinic or at the bedside. As rehabilitation professionals often spend large amounts of time with their patients and get to know them well, they may be the first healthcare professional to note the possibility of PAD. Simple and efficient bedside screens allow the rehabilitation professional to gather information and initiate the appropriate referral.

	Screening reasoning	Procedure	Test example (click to enlarge)
Dorsalis pedis pulse	The dorsalis pedis artery is the supplier of blood to the foot. A weak dorsalis pedis pulse may signify an underlying circulatory condition such as PAD.	possible to visualize this pulse locate palpation point by asking patient to lift their great toe, the artery is located just lateral to this tendon pulse is located just past the midfoot towards the ankle region document which grading scale is being used
Posterior tibial artery pulse	The posterior tibial artery provides blood flow to the posterior compartment of the leg. A weak posterior tibial pulse may signify PAD or compartment syndrome.	locate the palpation point midway between the medial malleolus and the Achilles tendon document which grading scale is being used
Capillary refill time (CRT)	CRT is a physical exam technique which provides a quick and reliable assessment regarding the adequacy of peripheral perfusion in both adults and children. beneficial to perform when patient has absent or deminished posterior tibial or dorsalis pedis pulses	provide light compression at the end of a digit or the skin just distal to a wound or area of concern until the colour disappears (blaunches) release the pressure and count how many seconds until the skin returns to its original colour a normal CRT is less than three seconds
Rubor dependency test	Bedside exam to assess for PAD Dependent rubor is a fiery-red to dusky-red coloration to the skin when the leg is in a dependent position but not when it’s elevated above the heart	the limb is elevated to 60 degrees from horizontal for 60 seconds examine the sole of the foot and assess for palor. PAD causes the soles to change from pink to pale in people with fair-skin and to gray or ashen in people with dark-skin. Pallor within 25 seconds of leg elevation indicates severe occlusive disease. The more quickly the pallor appears, the worse the PAD. then it is moved to a dependent position by assisting the patient into a sitting position a limb with normal profusion will return to a healthy colour within about 15 seconds of being lowered	Please view video below for example of how to perform exam.

Please view the following optional short video for a demonstration of how to perform the CRT and rubor dependency test.

If these screening tests are positive, the patient should receive an ankle-brachial index test (ABI).  It assesses the severity of arterial insufficiency of arterial narrowing during walking. ABI is measured by dividing the ankle systolic pressure by brachial systolic pressure. Normal ABI is between 0.90 and 1.30, a lower score may indicate PAD, a higher score may be a sign of arterial calcification.

Other tests that may be considered are the (1) toe-brachial index, (2) transcutaneous oxygen pressure, or (3) segmental perfusion pressure. The gold standard to diagnose PAD is contrast angiography, which is an invasive exam.

PAD risk factors

Risk factors for PAD and arterial ulcers:

1. Smoking. Cigarette smoking doubles the risk of PAD. The risk increases cumulatively with the number of cigarettes smoked and the number of years spent smoking.
2. Age above 60 years
   • 5-10% of those aged 50 to 80 years
   • 20-30% of those over 80 years
3. Diabetes. Patients with diabetes have two to three times the increased risk of PAD.
4. Hypertension
5. High cholesterol
6. Atherosclerosis. However, it is important to note that not all PAD is caused by atherosclerosis. Health screening and referral to the appropriate healthcare provider can assist with formal diagnosis.
7. Sedentary lifestyle
8. Family history

Both sexes are affected by PAD, however biological males are more likely to present with claudication symptoms and biological females are more likely to be asymptomatic.

PAD differential diagnosis

Spinal stenosis, a condition commonly treated in rehabilitation clinics, can present with symptoms similar to peripheral arterial disease. It is important to be able to differentiate between the symptoms of these conditions, but also to be aware that they can also both occur simultaneously.

• Ischaemic claudication pain associated with PAD:
  • in the early stages can be relieved with rest
  • in the later stages pain is present at rest and does not change except when the limb is placed in a dependent position
• Spinal stenosis claudication pain:
  • typically relieved with a change in position that reduces the compression at the spine, such as moving from standing to sitting; sitting to lying; extension into flexion.
• Looking at the other signs and symptoms of PAD will also help to differentiate between the two.

Arterial wound characteristics

• Occur on the lower third of the leg
• Often seen on the lateral side and distally, ie: the mid-tibia region, the lateral malleolus, the toes, the web spaces, and the heels
• Wound bed tends to be pale with well-defined edges or a punched out appearance
• Wound bed is typically dry and has minimal drainage. It does not usually bleed
• Necrotic tissue is common, especially black eschar
• The skin is pale, darkened, or cyanotic
• The area of skin around the wound is commonly shiny, brittle, and hairless
• May observe slow-growing, brittle, or rigid toenails
• The posterior tibial and/or dorsalis pedis pulses are diminished or absent
• The lower leg is often cool to the touch and muscle atrophy can be observed in the calves or feet
• Arterial wounds are typically quite painful, pain is often worse with elevation. In the later stages of PAD, pain at rest and burning in the toes and soles of the feet is common.

Symptoms of PAD and arterial wounds:

• Slow healing wounds
• Feet usually feel "cold, tingly or numb"
• Muscle cramping is common, especially with exercise or exertion in daily activities such as stair climbing

How PAD pain can effect rehabilitation assessments:

• Pain symptoms are often reported unilaterally. However approximately 80% of patients have significant bilateral disease, if one side is more severe, it may be masking symptoms on the contralateral side.
• Pain is commonly relieved with dependency position which can result in oedema in the limb. This is significant for differential diagnosis with venous disease.
• Ambulation tolerance is limited by pain, cramping, or weakness after a few blocks distance. Watch for expected patterns of pain improving with rest for differential diagnosis with other types of walking pain.

Arterial wound management

Okay. So now let's talk about the three most important factors in arterial wound management. So even if you're not doing these things, you know how to educate and who to refer to. The first is perfusion. It's very important to address this before anything else. Tissue perfusion needs to be restored as soon as possible. So avoid compression and elevation in these patients. If your screening tests indicate poor perfusion, the patient should receive an ankle-brachial index test or a referral back to the doctor or to a vascular specialist for more testing. The next most important thing is smoking cessation. So while this is important for all wounds, many other health issues, this is especially a priority for those with PAD. This is the largest modifiable risk factor for arterial ulcers. Smoking just one cigarette reduces tissue oxygenation concentrations. Smoking cessation has been shown to restore the tissue microenvironment and cellular functions within about four weeks time. And then that continues the longer that they abstain from smoking. The third most important factor is nutrition. So adequate hydration along with reducing trans fats and inflammatory foods will all help to manage blood pressure, cholesterol, and inflammation. Ideally, each patient should work with a dietitian to develop a customised nutrition plan, but a list of basic inflammatory foods can be found in the resources section for this course. For hydration of an otherwise healthy person, an average recommendation is to take the body weight in pounds and divide by two to get the number of ounces of water per day, or approximately 25 to 30 millilitres of fluid per kilogram of body weight. So if someone is healing from a wound, has other health conditions, a diet with low water content, lives in an environment that's really dry or really humid, they may have different water requirements. And this is why a personalised assessment is really important, but that gives you a baseline of perhaps where to start.

Venous Insufficiency Wounds or Venous Ulcers

Moving on to venous insufficiency wounds or venous ulcers. This is the most common type of chronic wound accounting for more than 70% of all leg ulcers and it is the result of venous insufficiency. Approximately one-third of adults have venous insufficiency and the prevalence increases with age. It is about three times more common in biological females than biological males. This is primarily due to the effect that estrogen and progesterone have on vein function. It is important to note that about a quarter of those with CVI will have concomitant arterial disease and they should be screened for this mixed presentation, okay, with the perfusion tests that we discussed before.

Venous ulcer characteristics

The characteristics of CVI and venous wounds. They occur on the lower third of the leg in the gaiter area and are more common on the medial side, although they can occur laterally as well. Examples are above the medial or lateral malleolus. If the wound occurs directly on the malleolus, on the calf, or on the proximal lower leg, it's not likely to be a venous origin. Venous wounds are of insidious onset and they are often proceeded by changes in colour and the texture of skin. So it may appear inflamed, thickened, crusty, scaled, shiny or tight. Typically redness is seen in lighter skin tones and a purple-grey or ashen tone is seen in darker skin tones. These are signs of stasis dermatitis. The next sign is varicose veins. They may be present, but it's not always the case. There can be insufficiency of the deep system without it manifesting in the superficial system. The next is staining of the skin. Haemosiderin staining is a brownish speckly staining of the skin that is a result of the breakdown of red blood cells and haemoglobin molecules that become trapped in the skin after being leaked from distended vessels. Atrophie blanche is a whitish discolouration due to occlusion of the small vessels in the skin. So it can be seen in skin that has healed ulcers and may also be seen as a precursor to ulceration. Venous wounds tend to be shallow, they have uneven edges and a granular or a gelatinous fibrotic base. This is in contrast to the punched out appearance of arterial ulcers. Yellow slough may be seen, but black or brown eschar is rare. Venous wounds tend to be wet. Serous exudate seeps from the wound, and then also sometimes from the surrounding skin. So you'll tend to see a lot of exudate with these types of wounds.

Chronic oedema is worse after prolonged standing. So initially, this oedema is pitting, which means an indent stays when you press on the skin. In more advanced disease, this oedema may become firm and a 'woody' consistency. And this is due to fibrosis of the underlying tissue. This presents as a dark, discoloured, firm, and nonpitting oedema. Late stages of the disease may present with a 'champagne bottle' shape of the lower leg. It's important to note that oedema in CVI is generally only observed below the knee. So if the oedema extends up into the thigh, it's more likely to be due to lymphoedema than venous insufficiency. CVI oedema is also more likely to be unilateral, although in long-standing disease, you may see it bilaterally. It's still more likely to be more severe on one side compared to the other. If oedema is bilateral and equal, it is more likely due to medications or another systemic condition like congestive heart failure or something along those lines. Pulses are not typically absent in venous insufficiency, except in cases of severe oedema where there's so much swelling that it interferes with palpation of the pulse. Finally, the lower leg is typically warm to the touch. Now this is in contrast to arterial ulcers where the limb is typically cool to the touch.

So let's talk about symptoms of CVI and venous ulcers. You will commonly see wounds that tend to improve and regress multiple times. 60-70% of those that have had a venous wound will have a recurrence within 10 years. So these are ones that come and go a lot of the time, you will often see aching or cramping in the leg. This is due to distension of the vessels, blood pooling in those muscles, and then reduced oxygenation to the tissues. The leg will also feel heavy or tired. This is due to the oedema and the reduced oxygenation. So that's a common thing that you hear. Itching or tingling of the skin is really common, especially when you've got stasis dermatitis. This is due to distension of the vessels, and then the inflammation that's caused by the accumulation of all that fluid and proteins that are in the interstitial spaces. Discomfort is often seen or relieved with elevation, sorry, and worsened with dependency or prolonged standing. This is in contrast to the relief with dependency with arterial ulcers. The patient may see symptoms of frequent urination at night. So, because the legs are elevated, the fluid is draining. The kidneys have to offload that, but keep in mind that this symptom could be due to other causes as well. Finally, the lower leg may ache. Venous wounds are typically not as painful as arterial wounds, but they sort of report more aching of like the whole leg region.

CVI screening

Let's talk about clinical screening for CVI. Examination should begin with an assessment of the skin, looking for visible varicose veins, oedema, any skin changes that are commonly seen with VIN, venous insufficiency. Those are going to tip you off right away. The next is to look at arterial circulation with palpation of the posterior tibial and dorsalis pedis pulses. If these are not palpable, check capillary refill. If it is intact, the lack of pulses are more likely due to venous oedema that's interfering with your palpation rather than due to arterial insufficiency occluding the vessels. And finally, the Brodie-Trendelenberg's and Perthe's tests can be used clinically to test for venous backflow and links to these tests can be found in the resources for this course.

Venous ulcer management

Okay, let's look at the three most important factors for venous wound management. The first is, hands down, compression. With an open wound, the patient should have compression dressings that are changed regularly to keep up with the leg circumference. That might mean every other day or every three to four days, depending on their situation. These dressings are kept on 24 hours a day and they should not get wet. So care needs to be taken with bathing. Once the wounds have healed and oedema is stable. The limb should be measured for custom compression stockings. These should be worn all day but can be removed for sleep. Prior to applying any compression you need to ensure that the patient has adequate tissue perfusion and that the level of compression is appropriate for them. So this requires an ankle-brachial index testing. If the patient already has compression stockings, it's important to ensure that they still fit and that they are wearing them. So these typically need to be changed every six months. And if possible, the patient should have two pairs so that they have something to wear while one of them is being washed. The next important thing is nutrition. As discussed with arterial ulcers, you need to ensure adequate hydration and reduce foods that can cause inflammation of the blood vessels. Again, if possible, each patient should work with a dietitian to develop a customised nutrition plan, but if that's not possible, some of the general recommendations in the resource section can be beneficial to sort of get them at least started on the right path.

The next important thing is exercise. A few ideas are a walking programme or bicycling. So these have the advantages of many other health benefits, right? The next is soleus stretches and ankle mobility to optimise ankle joint range of motion. Ankle pumps, circumduction, ankle alphabet, heel-toe raises in both sitting and standing positions. Ankle rocker board exercises. You can also use an exaggerated heel-toe sequence during ambulation or over a step. And you can combine these exercises with elevating the leg higher than the heart to maximise the benefit. So now you're using gravity and then you can still do all those exercises that's going to activate the muscle pump and all of that is going to be feeding to getting the fluid out of that limb.

Resources

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