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222 MUSCULOSKELETAL FACTORS IN LEG ULCERS
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CHAPTER
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5
Assessment ofLeg Ulceration
KAREN STAINES AND ABY MITCHELL
leg ulcer is a break in the skin below the knee that has not
A
healed within a two- week period (NICE2021). A lower limb
assessment is essential to identify the risk factors for developing leg
ulceration and delayed healing. There is currently no pathway for
preventing primary leg ulcers and management in clinical practice
tends to be reactive rather than proactive. According to the Commissioning for Quality and Innovation system (CQUIN; CCG11), all
patients should receive a full lower limb assessment following
referral to a service within 28days of a non- healing wound. A holistic lower limb assessment includes patient assessment, leg assessment and wound and skin assessment (Wounds UK2022) and it is
essential to identify contributory and causative factors to aid in
diagnosis (Mitchell2020). Accurate and timely wound assessment
underpins eective clinical practice, decisionpatient- centred goals and reducing morbidity and costs associated
with long- term wound care. Furthermore, early assessment,
diagnosis and intervention are essential to reduce the burden of
venous disease and improve quality of life (Mitchell and
Elbourne2020). Fundamentally this is where understanding and
patient partnership start.
making, improving
Lower Limb and Leg Ulcer Assessment and Management, First Edition.
Edited by Aby Mitchell, Georgina Ritchie, and Alison Hopkins.
© 2024 John Wiley & Sons Ltd. Published 2024 by John Wiley & Sons Ltd.
226
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Assessment of Leg Ulceration 227
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ASSESSMENT
It is essential to establish the underlying cause of leg ulceration to
avoid misdiagnosis and unnecessary delays in healing (Wounds
UK 2016). All patients with a wound on the lower limb should be
assessed to determine the vascular status of the limb prior to commencing treatment with strong compression therapy. In the absence of
red ags, mild compression therapy can be commenced immediately
to prevent deterioration while the person awaits full assessment,
including assessment of the ankle brachial pressure index (ABPI). This
is referred to as ‘early intervention’ and is advocated by the National
Wound Care Strategy; it is explained in more detail in Chapter 9.
Wound care should be considered a specialist segment of healthcare
that requires additional training to assess, diagnose and manage (Guest
etal.2015). Leg ulcer assessment is a complex skill and should only be
undertaken by healthcare professionals who have the appropriate level
of skills and prociency (Mitchell 2017). A structured assessment is
key to gathering and interpreting data about the patient, conrming
the patient’s specic requirements and reasons for assessment.
Good history taking is pivotal to decision- making and will form
the basis for multifaceted diagnoses including medical, psychosocial
and psychological. (See Chapter7 for a focus on developing personalised assessment.) A full medical history should also include any
co-
morbidities or surgical procedures, which may be causative fac-
tors in the development of a leg ulcer.
HISTORY TAKING
Age
Increasing age leads to degenerative changes and atrophy of the
smooth muscle layer in the vein, which increases susceptibility to dilation (Robertson2013) and thus the presence of venous disease. The
presence of peripheral arterial disease (PAD) also increases with age.
Family History
A family history of venous disease is commonly associated with valve
dysfunction leading to venous hypertension (Ortega etal.2021). Ask
the patient if any rst- degree relative has a history of telangiectasis,
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varicose veins, blood clots in the lower limbs, a current or previous leg
ulcer, phlebitis, pulmonary embolism or any other venous problems
(Cirqui etal.2007). If both parents have varicose veins, the ospring
have a 90% chance of developing them (Collares and Faintuch2017).
Medical History
Check the patient’s medical status and whether ongoing medical
support is required for any pre- existing conditions.
Medications
Medications and their side eects may cause a delay in wound healing, make the person increase the risk of wound infection or be a
contributory factor in ulceration. There are certain medications that
can exacerbate and further increase the risk of leg ulceration, as discussed (see Chapter8). It is important to discuss medications with
the person and the prescriber.
Previous Surgery
Limb, abdominal, bypass or amputation surgery may cause disruption and damage to the circulatory system. A venous thrombus episode (VTE) can occur in between 10% and 14% of patients after major
abdominal surgery (Theochari etal.2022).
Deep Vein Thrombosis
People who have a history of deep vein thrombosis (DVT) have an
increased risk of ulceration due to damage to the deep veins.
Previous Trauma
There is an increased risk of DVT following a fracture of the lower
limb (Mioc etal.2018). Any break in skin integrity from trauma can
also inuence the disruption to the lymphatic system (Minasian
etal.2022). The supercial lymphatics can be found in the dermis
layer of the skin, resulting in an increase in localised oedema if these
become damaged.
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Haemorrhoids andConstipation
Ask the patient if they are suering from haemorrhoids and/or
constipation. The results of the CHORUS study found that over 50%
of patients who had a history of haemorrhoids and constipation also
had venous disease with a CEAP classication (see Table 5.2) up to
C2 (Godeberge etal.2019).
Diabetes/Associated Peripheral Neuropathy
People diagnosed with diabetes are at greater risk of having small
vessel disease and nerve damage, with one in four patients having
peripheral neuropathy (NHS2022). This can result in pressure damage occurring due to a lack of sensation without the patient feeling
pain. Furthermore, uncontrolled blood glucose levels can mean that
the person with diabetes has an increased risk of infection and
delayed wound healing. See Box5.1 on monolament testing.
Box 5.1 Monolament Testing forNeuropathy
Monolament testing is used in the presence of diabetes or when
there is concern about peripheral neuropathy being present.
Using a monolament is an inexpensive portable test for assessing
the loss of protective sensations in the foot. Monolaments are
single- bre nylon threads that generate a buckling stress; the
higher the value or weight of the thread, the harder it is to bend.
In normal practice a 10 g monolament is used at various
points on the plantar aspect of the foot. The patient is assessed
with their eyes closed or head turned so that they cannot see
where the monolament is being placed. They are to tell the clinician when they feel their foot being touched. A lack of response
needs to be checked, but will denote a lack of sensation and the
protective function.
This patient will then have a reduced pain response, which
has clinical implications for management and use of compression
therapy. Use local guidelines and referral mechanisms.
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Cancer Diagnosis or Treatment
Cancer itself can cause occlusion, depending on tumour location.
Cancer treatment can aect the lymphatic system, leading to an
increased risk of oedema. Radiotherapy and chemotherapy can
adversely impact the immune system and destroy cells, which delays
wound healing (Deptuła etal.2019).
Inflammatory andAuto- immune Conditions
People who have underlying auto- immune conditions can have an
increased risk of developing ulceration. Conditions such as pyoderma
gangrenosum and vasculitis may need medical management to guide
medication as well as wound management and compression therapy;
read more about this in Chapter3.
Haematological Disorders
Disorders of the blood may have contributed to the presenting
ulceration or reduced healing potential, depending on the type of
haematological disorder, such as sickle cell disease (SCD), anaemia
or haemophilia. People diagnosed with SCD are 10 times more at risk
of developing a leg ulcer than the general population (Young2020).
See Chapter3.
Respiratory Disorders
Chronic obstructive pulmonary disease (COPD) or similar respiratory
disorders may have increased oedema due to breathlessness. Caution
may be needed to ensure that compression therapy will not exacerbate
breathlessness. A quarter of patients with COPD have cor pulmonale
(right- sided heart failure), which can lead to increased oedema and
shortness of breath (Robinson and Scullion2021).
Cardiac Vascular History
Previous myocardial infarction or angina may indicate a reduction of
oxygenated blood that increases the chance of developing leg ulcers
and causes a delay in healing. People with a diagnosis of heart failure
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need to be carefully monitored and discussed with the wider
multidisciplinary team to ensure that any treatment will not cause an
increase in cardiac oedema. For most people, unless they are in
unstable heart failure, compression is a safe and necessary
intervention. See Chapter8.
Phlebitis
Inammation of the veins can again cause long- term damage and be
a causative factor for ulceration.
Hypertension
Patients may have hypertension from an underlying condition of
high cholesterol, previous myocardial Infarction (MI), transient
ischaemic attack (TIA), stroke or kidney disease and are at a greater
risk of cardiovascular disease. If not well controlled, this may also
result in an abnormal ABPI.
Infection
A local or systemic infection will delay wound healing.
Pregnancy
Ask if the patient is pregnant. Cyclical changes in females’ progesterone
levels aect the vein wall and valves. The risk increases during
pregnancy whereby blood volume is increased, and the enlarging
uterus can restrict venous return (Nicholls2005). Females who have a
history of pregnancy have an 82% higher risk of varicose veins
compared to those who have never been pregnant (Ismail etal.2016).
Allergies or Known Sensitivities
Patients with venous leg ulcers are prone to increased sensitivity.
This may occur after prolonged use of certain dressings or emollients.
The most frequent allergen groups are fragrances (30.5%),
antimicrobials (19.5%), topical excipients (19.5%), rubber accelerators
(13.5%) and topical corticosteroids (8%) (Tavadia et al. 2003). It is
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