1. Wounds and the Lower Leg
Brenda M King
Nurse Consultant
Sheffield Teaching Hospitals

2. The burden of chronic wounds
It was identified in 2012/13 there were around 2.2 million chronic wounds in the UK with an estimated cost of between £4 to £5 billion/year (Guest et al 2015)
Further analysis suggested the number of chronic wounds may increase by 11% per annum and numbers may reach 3.7 million with a cost estimated at 8 to 9 billion per annum by 2017
With good wound assessment and management much of this burden can be avoided
2/3rds of all wounds are on the lower leg

3. Poor management leads to high costs for NHS but what about the cost to the patient
Decreased quality of life
Physical, psychological and emotional issues
Pain, exudate, leaking, bulky bandages, embarrassment and malodour
Loss of work and unemployment
May affect normal daily activity such as holidays and swimming
May suffer from poor sleep
Financial burden for the patient

4. Have we got it right?

5. Wound type by location 2013

6. Further survey work locally
1 group of GP’s in one week 224 x 10 minutes appointments for wound care 37.3 hours
Single Point of Access (SPA) referrals to CN’s from to referrals for wounds
158 – from GP
303 – from wards
28 – from OPD
93 – other

7. Why does an acute wound become chronic?

8. NHS work streams for wound care
Wound assessment minimum data set
CQUINS for wound assessment
Economic analysis
Wounds of the lower leg pathway
React to red
Education and competencies
Primary and community services commissioning guidance

9. January 2017
RightCare scenario: The variation between standard and optimal pathways
Betty’s story: Wound Care
Appendix 1: Summary slide pack
January 2017

10. Definition of leg ulcer
A leg ulcer is a wound on the on the lower leg that takes longer than:
6 weeks to heal (Moffatt 1994)
4 weeks to heal (SIGN 2012)
2 weeks to heal (NICE 2015)

11. Lower leg ulcers
A wound to the lower leg usually results from disordered circulation and treatment should be aimed at the underlying cause not just the wound dressing. However, there are other causes of lower leg wounds which may need specialist referral.

12. Causes of ulcers Vascular disease Neoplasms Metabolic disease
Physical and traumatic
Lymphoedema
Infections
Haematological disease
Immunologic / vasculitides

13. Vascular Disease Circulatory Disorders 95% of all leg ulcer

14. Circulation
Arteries
Veins
Lymphatics

15. Arterial disease Atherosclerosis
Reduced blood supply
Poor oxygenation
Arterial disease may affect any vessels in the arterial tree but is more common in some vessels including those supplying blood to the lower extremities
Arterial disease affects the lining of the arteries and is the development of atherosclerosis, commonly referred to as plaque. This narrows the lumen of the artery therefore reducing velocity and the amount of arterial blood able to pass through the artery and reducing the availability of oxygen and nutrients to the tissues. This would result in tissue ischaemia and may lead to tissue breakdown and ulceration. It is essential that any element of arterial disease is identified and a referral made to a vascular surgeon for further assessment.
Therefore it is essential when assessing a lower leg wound that we can recognise the presence of arterial disease, the signs and symptoms of reduced arterial blood flow and are able to undertake investigations to measure the amount of arterial blood flow reaching the lower extremities and factors which would increase a persons risk of having arterial disease. These will be covered in the assessment section
Once the tissues have been supplied with the oxygen and nutrients they require it is equally important that the waste products of metabolism are removed from the tissues and the blood is returned back to the heart to be reoxygenated and this is via the venous circulation
Ischaemia
Vessel occlusion
Necrosis

16. Risk Factors Arterial Disease
Hypertension
Diabetes
Smoking
Hyperlipidemia
Hormonal
Hereditary
Obesity
Physical inactivity
Stress

17. Predisposing/history arterial
Diabetes
Hypertension
History of smoking
Heart disease/ angina
H/O claudication
Rheumatoid arthritis
CVA
Arterial surgery

18. Venous circulation Deep fascia Saphenofemoral valve
Femoral vein (2 valves)
Popliteal vein (2-3 valves)
Short saphenous vein (up to 12 valves)
Perforating vein (with valves)
Long saphenous vein (up to 20 valves)
Ankle perforators
Saphenofemoral valve
The venous circulation is required to remove the waste products of metabolism from the capillary bed. The blood is transported back to the heart from the capillary bed into the venules, then into superficial venous circulation, which lie outside the muscle layer, through the perforator vessels, which perforate the muscle fascia and into the deep veins, which take the venous blood out of the leg. Venous blood flow is controlled by the action of muscle pumps the flow being controlled by the presence of valves, which will only allow blood flow in one direction, which is upwards towards the heart. There are a number of pumps including the planter muscle pump, the calf muscle pump, the popliteal pump, the groin pump, the abdominal pump and the respiratory pump. The most important pump for removing venous blood flow from the lower legs when an upright position is being adopted is the calf muscle pump. As the muscle contracts it squeezes the blood in the deep vein and forces it through the vessels in an upwards direction, flow being controlled by the action of the one way valves in the vessels. When the calf muscle relaxes it allows the deep vein to fill again from the superficial venous network
When this venous circulatory system is damaged it affects the normal return of venous blood flow back to the heart leading to a high pressure in the superficial venous system and venous insufficiency develops due to incompetence of the veins and valves
The image above shows a diagrammatic representation of the normal anatomy of the venous system

19. Backflow of blood from a deep vein into a superficial vein due to damaged valves in the perforating vein
Deep vein thrombosis
Superficial vein becomes dilated and tortuous, under abnormally high pressure (‘varicose vein’)

20. Incompetency of deep and perforating veins
Backflow into superficial veins
Pressure in superficial system rises in excess of 90 mm/Hg
Venous hypertension
Increased capillary pressure
This incompetence of the deep and perforating vessels where the valves fail to close and the vessels fail to effectively remove venous blood leads to a condition of venous hypertension where the pressure in the superficial venous system rises in excess of 90mm/Hg creating a very high pressure, normal pressure being around 30mm/Hg. This affects the pressure in the capillary bed and the upsets the equilibrium and normal exchange of nutrients and collection of metabolic waste, which remain in the tissue bed
If untreated this will lead to trophic skin changes, which predispose to venous ulceration.
Dilated porous capillaries leak
Water
Haemoglobin
Enzymes
Fibrin

21. Predisposing factors venous
Leg injury
Pregnancy
Deep vein thrombosis
Phlebitis
Constipation
IVDU history
Episodes of immobility
Family history
Varicose veins
Previous treatment of varicose veins
Previous surgery
Joint disorders such as arthritis
When considering the venous circulation and factors which can damage this and lead to venous hypertension these are some of the risk factors, which the patient needs to be assessed for and include deep vein thrombosis, a family history of ulcers, varicose veins, previous surgery or treatment of varicose veins, episodes of immobility, previous abdominal or groin surgery and joint disorders such as arthritis.

22. Indicators of venous disease
Lipodermatosclerosis
Venous eczema
Ankle flare
Atrophe Blanche
Brown staining
Tired Aching Legs
Varicose veins
Oedema

23. Assessment
Essential to identify underlying pathology in the limb. Includes:
Past medical history
Previous venous / arterial disease
Predisposing factors
Pain assessment
Clinical investigations - Doppler - Blood screen - Glucose / Hb - Nutritional

24. Treatment Aimed at the underlying cause
Venous insufficiency increasing venous blood flow back to the heart
Arterial disease - improving arterial blood flow to the limb
Good diabetic control
Appropriate referral to specialists - Vascular - Diabetologist - Medical - Dermatology

25. LEGS MATTER RESHAPING CARE TOGETHER legsmatter.org

26. Legsmatter.org
A coalition of healthcare organisations that are undertaking a united stand to make sure lower leg and feet conditions receive the urgent attention they need.
Many of us in this field had become increasingly concerned about the situation and we decided to see if we could achieve more by working together.
We are inspired by the ‘Stop the pressure’ campaign around reducing the incidence of pressure damage.
We want leg ulceration to receive at least the same level of attention as pressure ulcers.
We have agreed to develop and deliver a campaign to promote good quality care of the lower leg in the UK. .

27. PRIMARY OBJECTIVES To increase public awareness of lower leg problems.
To increase public awareness of what good care looks like so they know what to ask for.
More specifically, we want to ……..
To make the public (including patients, carers and those at risk – both male and female and of every age, from young pregnant women to the elderly) more aware of conditions of the lower leg and foot and the importance of seeking out the right treatment in a timely manner
To make the public aware of what type of care they can expect from healthcare professionals, and to empower them to demand better or different care when appropriate

28. PRIMARY OBJECTIVES
To educate healthcare professionals who are not tissue viability specialists about problems with the lower leg.
To empower tissue viability specialist healthcare professionals to continue to champion good care.
To educate healthcare professionals who are not tissue viability specialists on the signs, seriousness and implications of lower leg and foot conditions, and the importance of considering the lower leg and foot when assessing and treating patients.
To empower tissue viability specialist healthcare professionals to continue delivering championing better lower leg and foot care in their clinical setting

32. Conclusion
Any wound to the lower leg will become problematic if there are underlying circulation disorders.
Don’t wait for a wound to become chronic before full assessment is undertaken
Ensure a skilled workforce to assess and treat
Regular review