Leg Ulcers

Question 1

What is the definition of a chronic leg ulcer?

Answer 1

Open lesion between the knee and ankle joint that remains unhealed for at least 4 weeks

Question 2

What are type of ulcer are most leg ulcers?

Answer 2

Venous leg ulcers (60-80%)

Question 3

How common are other types of leg ulcers, besides venous ulcers?

Answer 3

22% arterial disease
9% rheumatoid arthritis
5% diabetic
10-20% mixed arterio-venous

Question 4

What is the UK prevalence of leg ulcers?

Answer 4

0.1-0.3% (increases with age), about 1% of population will have leg ulcer at some point

Question 5

Where are most chronic venous leg ulcers treated?

Answer 5

In the community (>80%), 12% treated as joint effort between community and secondary care, 5% treated as in-patient

Question 6

How can leg ulcers impact on patients?

Answer 6

Reduce quality of life, distressing symptoms (pain, leakage, smell, infection, social isolation)

Question 7

How much does it cost to treat one leg ulcer?

Answer 7

£1500 per annum

Question 8

Why do leg ulcers cost so much?

Answer 8

Delay in full assessment and diagnosis
Delay in ABPI’s or none at all
Delay in commencing treatment
Lack of confidence in compression application
Expensive dressings and inappropriate use

Question 9

What are the types of leg ulcer?

Answer 9

Venous, arterial (or mixed arterio-venous), vasculitic, malignant, inflammatory, hydrostatic (dependant limb)

Question 10

Why are holistic assessments of leg ulcers important?

Answer 10

They help determine the cause of the ulcer

Question 11

What are the main aims of assessment?

Answer 11

To identify clues to the underlying aetiology and factors contributing to delayed healing (SIGN 2010 suggest the use of an assessment tool)

Question 12

What order should the assessment follow?

Answer 12

Assessment of patient, then leg, then the ulcer itself

Question 13

What should be included in the assessment of the patient?

Answer 13

Past medical history, current medication, social circumstances, smoker (past or present), mobility, pain, sleep disturbance

Question 14

What should be recorded in the assessment of the ulcer?

Answer 14

Its position, measure surface area

Question 15

What are some features of vasculitis?

Answer 15

Painful, sudden onset, purpuric rash/pustules, necrotic

Question 16

What are some investigations that can be done for a leg ulcer?

Answer 16

ABPI
Wound swab
Bloods (FBC,LFTs, U+Es, CRP)
Patch testing (to previous ulcer treatment e.g bandages, cream)
Duplex scan (if indicated)

Question 17

Why should ABPI be done?

Answer 17

To establish if there is arterial disease

Question 18

When should a wound swab be taken?

Answer 18

Only if ulcer is increasingly painful/exudate/malodour/enlarging

Question 19

What does ABPI stand for, and what are the diagnostic ranges?

Answer 19

Ankle/Brachial pressure index:
1.0 = normal
0.8-1.3 = compress
<0.8 = vascular disease
>1.5 = calcification
(according to SIGN 2010)

Question 20

How should venous leg ulcers be treated?

Answer 20

Control pain and use ABPI
Non-adherent dressing (seldom heal wounds on their own)
De-sloughing agent if necessary (e.g hydrogel, honey)
4 layer compression bandaging (may need to increase compression)
Leg elevation

Question 21

What are some features of compression stockings?

Answer 21

Class 1 (weak) to class 3 (strong), most patients tolerate class 2 stockings, latex/rubber free if possible, non-adherent dressing

Question 22

How does the 4 layer bandaging system work?

Answer 22

By using graduated compression, leg padded to cone shape and changed weekly (or as required)

Question 23

What should the pressure be at the ankle and below the knee when using the 4 layer bandage system?

Answer 23

40mmHg at ankle, 25mmHg below knee

Question 24

Who should apply compression stockings?

Answer 24

A trained nurse

Question 25

What are the different types of debridement?

Answer 25

Autolytic
Sharp debridement (with scalpel, scissors)
Biological (larvae therapy)
Surgical (under general anaesthetic)

Question 26

How can wound beds be prepared?

Answer 26

By removing devitalised tissue by debridement

Question 27

How does autolytic debridement work?

Answer 27

Use of dressings to create moist wound environment and hydrate necrotic tissue/eschar

Question 28

How could huge cost savings be made?

Answer 28

If duration of ulcer reduced and prevention of recurrence addressed

Question 29

When is the aim for simple venous ulcers to healed by?

Answer 29

12 weeks