Assessment and Diagnosis

Recommendations

Identify and Treat the Cause
1 Take a careful history, including risk factors for atherosclerosis and signs and symptoms of venous and arterial disease. Level of Evidence
Not Assessed
2 Perform a physical examination, including a complete examination of the arterial and venous systems in all patients with leg ulcers. Evaluate the ulcer to narrow the differential diagnosis. Level of Evidence
Not Assessed
3 Perform neurological testing to diagnose or rule out diabetic neuropathy. Level of Evidence
Not Assessed
4 Diagnose infection based on a clinical evaluation and supported by microbiologic data. Level of Evidence
Not Assessed
5 Investigate suspected vasculitis to determine a specific diagnosis. Level of Evidence
Not Assessed
6 Determine the cause(s) and for possible chronic venous insufficiency based on etiology: abnormal valves (reflux), obstruction, or calf-muscle-pump failure. Level of Evidence
5
7 Treat the cause and implement appropriate compression therapy for venous disease in the absence of arterial predominant disease. Level of Evidence
Not Assessed
8 Implement appropriate medical therapy. Level of Evidence
Not Assessed
9 Consider surgical management (for venous (if significant superficial or perforator vein disease exists in the absence of deep venous disease) or arterial disease (bypass, dilation, or stent). Level of Evidence
Not Assessed
10 For nonhealable or maintenance wounds, provide support, pain control and modified local care (conservative debridement, bacterial and moisture reduction) Level of Evidence
Not Assessed
11 Perform the appropriate vascular investigations to diagnose or rule out arterial disease: at a minimum, an ankle-brachial index. Level of Evidence
Not Assessed
12 In patients suspected of having vessel calcification, a toe brachial index or assessment of Doppler arterial waveforms may detect arterial disease. Level of Evidence
Not Assessed
13 Perform duplex ultrasonography to identify lesions suitable for angioplasty. Level of Evidence
Not Assessed
14 Perform a hand-held Doppler examination to assess reflux in the superficial and deep venous system and to identify surgically correctable lesions. Level of Evidence
Not Assessed
15 Perform colour flow duplex ultrasonography to assess deep vein thrombosis and venous structure preoperatively. Level of Evidence
Not Assessed
16 Perform a hand-held Doppler examination to assess reflux in the superficial and deep venous system and to identify surgically correctable lesions. Level of Evidence
Not Assessed
17 Reserve invasive tests, such as angiography and venography, for preoperative evaluation if additional information, not provided by non-invasive testing, is required. Level of Evidence
Not Assessed


Address patient-centered Concerns
18 Communicate (patients, family, caregivers) to establish a social support system with realistic expectations for healing and to prevent leg ulcer recurrences. Level of Evidence
Not Assessed
19 Assess / Control pain and optimize activities of daily living Level of Evidence
Not Assessed


Provide Local Wound Care
20 Assess and document the wound at regular intervals. Level of Evidence
Not Assessed
21 Optimize local wound care: debridement, inflammation / infection control, and moisture balance. Consider biopsy of appropriate active (including biologicals) & adjunctive therapies if the wound is not healing at the expected rate. Level of Evidence
Not Assessed
22 Biopsy ulcers that are not healing despite appropriate care to identify malignancy. Level of Evidence
Not Assessed


Provide Organizational Support
23 Consult appropriate disciplines to maximize healing (e.g. mobility and nutrition). Level of Evidence
Not Assessed


Background

Leg ulcers are associated with a significant quality-of-life impact for patients and their families and a substantial economic impact for the healthcare system. Vascular pathology is associated with the majority of leg ulcers. Almost 70% of leg ulcers have a venous etiology; approximately 20–25% are due to arterial insufficiency; and some of these have a mixed vascular etiology. The remaining causes include infection, malignancy, vasculitis and other conditions. The prevalence of leg ulcers has been reported to be 0.12 – 0.32% of the general population and 1–2% of adults. Most patients are at least 65 years of age. Comorbidities are common, and serious complications, such as cellulitis, osteomyelitis, gangrene and amputation, may develop.

An interdisciplinary team with the knowledge and skills to assess and manage the problem, integrating the best evidence for practice and educating and involving patients in their care, can improve healing, reduce recurrence and improve quality of life.

Risk factors
Risk factors for venous ulcers include sustained venous hypertension associated with chronic venous insufficiency, varicose veins (pregnancy, long hours standing or sitting), deep vein thrombosis (DVT) and risk factors for DVT, congenital venous disease, lack of physical activity, immobility or paralysis; trauma, causing saphenous vein damage; joint disease or surgery of the leg resulting in joint fixation, trauma, obesity, congestive cardiac failure, increasing age, smoking, and female sex. Ischemia due to peripheral arterial disease (PAD) causes arterial ulcers. Associated risk factors include smoking, diabetes, hypertension, dyslipidemia, hyperhomocysteinemia and increasing age.

Differential diagnosis
· Venous ulcers tend to be shallow and moist and situated on the gaiter area of the leg. Edema, eczema, varicose veins, ankle flare, hyperpigmentation, atrophie blanche, and lipodermatosclerosis may be present. Superficial phlebitis may be present, usually affecting the saphenous vein. Associated pain may be aching, especially at the end of the day, and relieved by leg elevation.
· Arterial ulcers usually have a punched-out appearance, with a pale, dry poorly perfused base. The foot and leg may be cold, pale or bluish, with shiny, taut skin and dependent rubor, and possibly gangrenous toes. Arterial ulcers are often painful, especially after exertion or leg elevation.
· Mixed arterial/venous or venous/arterial ulcers demonstrate a range of features of venous and arterial ulcers, depending on the relative contribution of both problems.
· Neuropathic ulcers are generally found at sites of pressure, such as the heels or toes, and are accompanied by numbness and paresthesias. Neuropathic ulcers may involve tendon, fascia, joint capsule or bone and be surrounded by a callus. Sinus tracts may be present.
· Vasculitic ulcers may be multilocular, extremely painful, and surrounded by livedo and petechiae. These ulcers may be associated with a variety of disorders.
· Pyoderma gangrenosum ulcers begin as tender erythematous nodules and progress to painful ulcers, sometimes with undermined borders, surrounded by hemorrhagic sterile pustules.
· Infectious ulcers may develop as a result of bacterial infection at the site of minor trauma. The ulcer may be deep, with sharp margins and a necrotic ulcer bed.
· Malignancy, especially skin cancers, may present as an ulcer, often with an indistinct base and raised, rough or scaly edges with changes in the surrounding skin consistent with chronic sun exposure. These may enlarge rapidly, be associated with pain and bleeding and have a rolled margin.
· Less common causes of ulceration may require specific tests for identification.

Assessment and diagnosis
The history should evaluate general health; risk factors for atherosclerosis; signs and symptoms of ischemic vascular disease, such as intermittent claudication; medical conditions affecting the venous system, such as Raynaud’s disease; previous DVT; history of varicose veins, including previous stripping; pregnancies; recurrent leg ulcers; coronary artery bypass grafting (CABG) using saphenous vein grafts; and ulcer pain.

Physical examination of the vasculature should include blood pressure measurement, a check for aortic aneurysm and edema, palpation of peripheral pulses, evaluation of the saphenous vein, identification of elevation pallor and dependent rubor, the Brodie-Trendelenberg test to assess venous reflux and incompetent valves in the perforating and junctional venous system, and examination of nail and skin colour and texture.

Assessment of the venous system of the leg may include the following investigations:
· Hand-held Doppler: This evaluation can detect reflux and venous pulsatility and identify surgically correctable venous disease
· Colour flow duplex ultrasonography: Although highly operator dependent, this test can provide both anatomic and flow data, allowing localization of reflux and detailed assessment of perforator and junctional veins before varicose vein surgery. This test can also detect DVT, including thrombus age, and clot size and mobility.
· Venography: The significant risks associated with venography generally restrict its use to providing detailed information necessary for reconstructive surgery.

Assessment of arterial status may require the following investigations:
· Ankle brachial index (ABI): ABI, the ratio of the systolic ankle pressure and the higher of the systolic pressures in the arms, is calculated for both legs. Most studies consider an ABI between 0.9 and 1.3 to be normal [note: CCS consensus conference on PAD, 2005]. An ABI below 0.9 indicates the presence of PAD, with values below 0.5 denoting severe ischemia. Values above 1.3 are associated with arterial calcification. Gross edema can confound ABI determination. If a falsely elevated ABI is suspected, a toe brachial index may provide a better indication of tissue perfusion.
· Transcutaneous oxygen pressure (TcpO2) measures microvascular perfusion. Values <20 mmHg in the area of the ulcer are associated with slowly healing or nonhealing ulcers; values of 20–30 mmHg are indeterminate; and values >30 mmHg are associated with adequate healing.
· Duplex ultrasonography: Duplex scanning can identify vascular lesions and determine their hemodynamic impact, differentiate between plaque and thrombus, assess plaque morphology, and identify lesions suitable for angioplasty. Duplex ultrasound does not predict functional impairment and ulcer healability. Calcification, edema and large amounts of subcutaneous fat can reduce visualization.
· Angiography: Due to the potential for significant complications, angiography is reserved primarily for preoperative evaluation and interventional procedures.

The optimal management strategy for an individual patient can only be developed by integrating results of vascular investigations, the history, physical examination, ulcer assessment and other investigations.

References

Essential Publications
1 Ankle to brachial pressure – unknown etiology – assessment and diagnosis Quality Indicator
 Type: Validation study
Caruana MF, Bradbury AW, Adam DJ. The Validity, Reliability, Reproducibility and Extended Utility of Ankle to Brachial Pressure Index in Current Vascular Surgical Practice, European Journal of Vascular and Endovascular Surgery 2005;29:443-451.
A systematic search was undertaken to locate articles addressing the validity, reliability, and utility of ankle to brachial pressure index for clinical and research use. This article provides a great deal of information about ABPI suggesting that it is useful in evaluating people with venous leg ulcers, atypical symptoms, and asymptomatic PAD.
2 Wound bed preparation classification system – Chronic wounds Quality Indicator
 Type: Validation study
Falanga V, Saap LJ, Ozonoff A. Wound bed score and its correlation with healing of chronic wounds. Dermatologic Therapy 2006;19:383-390.
This article describes a new wound bed preparation classification system and its predictive validity. Eight parameters: healing edges (wound edge effect), presence of eschar, greatest wound depth/granulation tissue, amount of exudate amount, edema, peri-wound dermatitis, peri-wound callus and or fibrosis, and a pink/red wound bed, are scored from 0 (worst score) to 2 (best score), for a total wound bed score (WBS) of 16. The WBS was found to predict wound closure in this sample of patients with venous leg ulcers. It may be useful in clinical practice and in research.
3 Wound Assessment Quality Indicator
 Type: Prospective Correlation study
Romanelli M, Dini V, Bianchi T, Romanelli P (2007). Wound Assessment by 3-Dimensional Laser Scanning. Arch Dermatol 143 (10): 1333-1334.
15 patients with venous leg ulcers were prospectively examined. The laser scanner system that was used to measure wound size in a patient with venous leg ulcers enables users to accurately acquire 3-dimesional digital models of various types of skin wounds. The mean ± SD time for a full scan acquisition on the wound area and volume was 3.6±1.4 minutes.
4 Special Assessment – Laser Doppler vs. Laser Speckle Imaging Quality Indicator
 Type: Correlation study
Stewart CJ, Forrester FKR, Tulip J, Lindsay R, Bray RC (2005). A comparison of two laser-based methods for determination of burn scar perfusion: Laser Doppler versus laser speckle imaging. Burns 31: 744-752.
Patients were scanned monthly in the 11 months period. Clinical assessment was done on the burn scar and burns were graded according to the standard Vancouver burn scar scale. Both Laser Doppler perfusion imaging (LDI) and Laser Speckle Perfusion Imaging (LSPI) yielded a relative measurement of tissue blood flow and both instruments have a linear response to blood flow over normal physiological ranges. The fast temporal response of the LSPI instrument could be used to monitor vascular response to mechanical or pharmacological interventions to study dynamic vascular changes to burn damaged tissues. It is favoured because of patient comfort.


Enablers for practice

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