Chronic Leg Ulcers

Original Editor - Lucinda hampton

Top Contributors - Lucinda hampton, Kim Jackson and Aminat Abolade  

Introduction

Chronic leg ulcer is defined as a defect in the skin below the level of knee persisting for more than six weeks and shows no tendency to heal after three or more months. Chronic ulceration of the lower legs is a relatively common condition amongst adults, one that causes pain and social distress.

The condition affects 1% of the adult population and 3.6% of people older than 65 years.

• Leg ulcers are debilitating and greatly reduce patients' quality of life. The common causes are venous disease, arterial disease, and neuropathy. Less common causes are metabolic disorders, hematological disorders, and infective diseases.
• As many factors lead to chronic lower leg ulceration, an interdisciplinary approach to the systematic assessment of the patient is required, in order to ascertain the pathogenesis, definitive diagnosis, and optimal treatment.
• The researchers are inventing newer modalities of treatments for patients with chronic leg ulceration, so that they can have better quality life and reduction in personal financial burden.

Aetiopathogenesis

It has been reported that ulcers related to venous insufficiency constitute 70%, arterial disease 10%, and ulcers of mixed etiology 15% of leg ulcer presentations. The remaining 5% of leg ulcers result from less common pathophysiological causes (this latter group comprise considerable challenges in diagnosis, assessment, and management).

Management of Chronic Leg Ulcers

An ideal management plan for patients with chronic leg ulcers should involve an early strategic and coordinated approach to delivering the correct treatment option for each individual patient, based on accurate assessment of the underlying pathophysiology.

The management of leg ulcers should include a detailed history of the onset of the problem, examination of the legs and skin, investigations, and modalities of treatments. Successful management of leg ulcers requires a clear diagnosis, establishment of a treatment plan, accurate monitoring, and adherence to the plan as the ulcer decreases in size. Education and training is vital for all those involved in caring for patients with chronic ulceration.

Education Of Client including the following advice.

• Important to keep any wounds clean to prevent infection. Wash the wound with mild soap and water daily. Also, change any bandages and dressings at least once daily to keep the area dry, so it can heal (follow specific routine doctor gives).
• Wear good walking shoes
• Get regular, mild to moderate exercise with compression bandages covering ulcer
• Elevating your legs during rest periods
• Never use home or alternative methods in lieu of traditional medical treatment without checking with your doctor. These remedies may very well be beneficial, but they can also aggravate the condition depending on the preparation and stage of your ulcers.

Wound management products

Passive dressings:

• Use the ‘passive’ or the ‘plug and conceal’ concept, including gauze, lint, non-stick dressings and tulle dressings. These products fulfill very few of the properties of an ideal dressing and have very limited, if any, use as primary dressing, but some are useful as secondary dressings.

Interactive dressings:

• These dressings help to control the micro-environment by combining with the exudate to form either a hydrophilic gel or, by means of semipermeable membranes, controlling the flow of exudate from the wound into the dressing. They may also stimulate activity in the healing cascade and speed up the healing process.

• There are six classes of interactive dressings, classified according to their functionality (The choice of dressing will depend on the wound type and depth, level of exudate and the presence of bacteria):
  1. Film dressings
  2. Hydroactive dressings
  3. Hydrocolloid dressings
  4. Hydrogel dressings
  5. Foam dressings
  6. Alginate absorbent fibre dressings.

Bandages

• Used from ancient times. In the past 15 years there has been an explosion in the types of bandages available. The bandage may be needed for several reasons:
  • Retention: keeping a dressing in place
  • Musculoskeletal support: supporting an injured joint
  • Compression: assisting venous return from the lower leg.

Physiotherapy

Physiotherapists are important members of wound care teams.  We have extensive knowledge of anatomy, physiology, electrophysical agents, and biomechanics to optimize functional strength, balance, and mobility.  We can use this knowledge to provide a holistic approach to our senior populations with chronic lower leg wounds.

The calf muscle pump is the primary mechanism to return blood to the heart from the lower extremities.(7)  When impaired, venous hypertension results from blood pooling in the lower extremities.(8)  Over 70% of individuals presenting with a venous leg ulcer have an impaired calf muscle pump.(7)  Providing resistive calf muscle strengthening exercises (i.e.: heal lifts, resistive dorsiflexion/plantar flexion exercises, walking with adequate ankle range) and/or improving ankle range of motion, have been shown in the literature to enhance lower extremity hemodynamics and positive trends towards venous leg ulcer healing.(9)  To evaluate the true effectiveness of exercise with respect to chronic lower leg wound healing and prevention, more robust studies are required.  Despite this, the importance of exercise for this population is recognized in the literature, and should not be overlooked.

Physical activity has also shown favourable impacts on psychosocial issues such as self-esteem, depression, anxiety, and stress.(10)  Prior to any exercise prescription, one must do a full assessment of the individual to ensure exercises provided are appropriate and will not cause harm to the client.

Exercise is recommended as an adjuvant treatment for venous leg ulceration (VLU) to improve calf muscle pump function.

• Prescribing exercise for treating VLU may have an added beneficial effect when used in addition to compression and it appears that the combination of progressive resistance exercises and aerobic activity may be the most effective form of exercise regimen.
• The evidence may now be sufficient to suggest clinicians and suitable patients could consider simple progressive resistance exercises eg heel raises, and 30 minutes walking at least 3 times per week.
• Adherence to such a regimen suggests that for every 4 patients treated with prescribed exercise plus compression, 1 more patient might heal than if using compression alone.

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