Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_781_Библиотеки_им_академика_М_И_Перельмана
.pdf
222 MUSCULOSKELETAL FACTORS IN LEG ULCERS
https://t.me/medicina_free
Jordan, J.E. and Osborne, R.H. (2007). Chronic disease self- management
education programs: challenges ahead. Medical Journal of Australia
186(2): 84–87.
Kan, Y.M. and Delis, K.T. (2001). Hemodynamic eects of supervised calf
muscle exercise in patients with venous leg ulceration: a prospective
controlled study. Archives of Surgery 136 (12): 1364–1369.
Kim, S.J., Shin, Y.-
induced by rhythmic auditory stimulation for adolescents with
acquired brain injury. Annals of the NewYork Academy of Sciences
1385 (1): 53–62.
Knox, E.C.L., Esliger, D.W., Biddle, S.J.H., and Sherar, L.B. (2013). Lack of
knowledge of physical activity guidelines: can physical activity promo-
tion campaigns do better? BMJ Open 3 (12): e003633.
Koepsell, T.D., Wolf, M.E., Buchner, D.M. etal. (2004). Footwear style and
risk of falls in older adults. Journal of the American Geriatrics Society
52(9): 1495–1501.
Langhammer, B., Bergland, A., and Rydwik, E. (2018). The importance of
physical activity exercise among older people. BioMed Research Interna-
tional 7856823.
Lattimer, C.R., Franceschi, C., and Kalodiki, E. (2017). Optimizing calf mus-
cle pump function. Phlebology 33 (5): 353–360.
Lee, I.- M. and Buchner, D.M. (2008). The importance of walking to public
health. Medicine & Science in Sports & Exercise 40 (7): S512–S518.
Lerebourg, L., L’Hermette, M., Menez, C., and Coquart, J. (2020). The eects
of shoe type on lower limb venous status during gait or exercise: a sys-
tematic review. PLoS One 15 (11): e0239787.
López- López, D., Araújo, R., Losa- Iglesias, E. etal. (2018). Inuence of cus-
tom foot orthoses on venous status: a quasi- experimental study. Journal
of the Mechanical Behavior of Biomedical Materials 79: 235–238.
Meissner, M.H. (2005). Lower extremity venous anatomy. Seminars in Inter-
ventional Radiology 22 (3): 147–156.
Menant, J.C., Steele, J.R., Menz, H.B. etal. (2008). Optimizing footwear for
older people at risk of falls. Journal of Rehabilitation Research and
Development 45 (8): 1167–1181.
Menz, H.B. (2021). Foot problems, footwear, and falls. In: Falls in Older Peo-
ple: Risk Factors, Strategies for Prevention and Implications for Practice
(ed. S. Lord, C. Sherrington, and V. Naganathan), 119–129. Cambridge:
Cambridge University Press.
Menz, H.B., Auhl, M., Tan, J.M. etal. (2016). Biomechanical eects of prefab-
ricated foot orthoses and rocker- sole footwear in individuals with rst
metatarsophalangeal joint osteoarthritis. Arthritis Care & Research
68(5): 603–611.
K., Yoo, G.E. et al. (2016). Changes in gait patterns
本书版权归John Wiley & Sons Inc.所有
Musculoskeletal Factors in Leg Ulcers 223
https://t.me/medicina_free
Meulendijks, A.M., Franssen, W.M.A., Schoonhoven, L., and Neumann,
H.A.M. (2020a). A scoping review on chronic venous disease and the
development of a venous leg ulcer: the role of obesity and mobility. Jour-
nal of Tissue Viability 29 (3): 190–196.
Meulendijks, A.M., Welbie, M., Tjin, E.P.M. etal. (2020b). A qualitative study
on the patient’s narrative in the progression of chronic venous disease
into a rst venous leg ulcer: a series of events. British Journal of Derma-
tology 183 (2): 332–339.
Milic, D.J., Zivic, S.S., Bogdanovic, D.C. etal. (2009). Risk factors related to
the failure of venous leg ulcers to heal with compression treatment.
Journal of Vascular Surgery 49 (5): 1242–1247.
Mills, K., Blanch, P., Chapman, A.R. etal. (2010). Foot orthoses and gait:
a systematic review and metapotential mechanisms. British Journal of Sports Medicine 44 (14):
1035–1046.
National Institute for Health and Care Excellence (NICE) (2021). Leg ulcer-
venous. https://cks.nice.org.uk/topics/leg-
Norkin, C.C. and White, D.J. (2016). Measurement of Joint Motion: A Guide to
analysis of literature pertaining to
ulcer- venous
Nussbaumer, S., Leunig, M., Glatthorn, J.F. et al. (2010). Validity and test-
retest reliability of manual goniometers for measuring passive hip range
of motion in femoroacetabular impingement patients. BMC Musculo-
skeletal Disorders 11: 1–11.
National Wound Care Strategy Programme (NWCSP) (2020). Lower limb
assessment essential criteria. https://www.nationalwoundcarestrategy.
net/wpAssessment- Essential- Criteria- Final.pdf
O’Brien, J., Finlayson, K., Kerr, G., and Edwards, H. (2014). The perspectives
of adults with venous leg ulcers on exercise: an exploratory study. Jour-
nal of Wound Care 23 (10): 496–509.
Padberg, F.T. Jr., Johnston, M.V., and Sisto, S.A. (2004). Structured exercise
improves calf muscle pump function in chronic venous insuciency: a
randomized trial. Journal of Vascular Surgery 39 (1): 79–87.
Palastanga, N. and Soames, R. (2018). Anatomy and Human Movement:
Structure and Function, 7e. Edinburgh: Churchill Livingstone.
Pirker, W. and Katzenschlager, R. (2017). Gait disorders in adults and the
elderly: a clinical guide. Wiener Klinische Wochenschrift 129 (3–4): 81–95.
Podsiadlo, D. and Richardson, S. (1991). The timed ‘Up & Go’: a test of basic
functional mobility for frail elderly persons. Journal of the American
Geriatrics Society 39 (2): 142–148.
Reina- Bueno, M., Vázquez- Bautista, C., Palomo- Toucedo, I.C. etal. (2020).
Custom- made foot orthoses reduce pain and fatigue in patients with
content/uploads/2021/04/CQUIN- 20- 21- Lower- Limb-
本书版权归John Wiley & Sons Inc.所有
224 MUSCULOSKELETAL FACTORS IN LEG ULCERS
https://t.me/medicina_free
Ehlers- Danlos syndrome. A pilot study. International Journal of Envi-
ronmental Research and Public Health 17 (4): 1359.
Ricci, S. (2020). Anatomy and venous hemodynamics of gait phases. Journal
of Theoretical and Applied Vascular Research 5 (3): 0831.
Saggini, R., Bellomo, R.G., Iodice, P., and Lessiani, G. (2009). Venous
insuciency and foot dysmorphism: eectiveness of visco-
rehabilitation systems on veno-
calf. International Journal of Immunopathology and Pharmacology 22
(3_suppl): 1–8.
Saxon, R.L., Gray, M.A., and Oprescu, F.I. (2014). Extended roles for allied
health professionals: an updated systematic review of the evidence.
Journal of Multidisciplinary Healthcare 7: 479–488.
Shiman, M.I., Pieper, B., Templin, T.N. etal. (2009). Venous ulcers: a reap-
praisal analyzing the eects of neuropathy, muscle involvement, and
range of motion upon gait and calf muscle function. Wound Repair and
Regeneration 17 (2): 147–152.
Simonsen, E.B. (2014). Contributions to the understanding of gait control.
Danish Medical Journal 61 (4): 1–23.
Smith, D., Lane, R., McGinnes, R. etal. (2018). What is the eect of exercise
on wound healing in patients with venous leg ulcers? A systematic
review. International Wound Journal 15 (3): 441–453.
Tinetti, M.E., Williams, T.F., and Mayewski, R. (1986). Fall risk index for
elderly patients based on number of chronic disabilities. American Jour-
nal of Medicine 80 (3): 429–434.
Uhl, J.-
F. and Gillot, C. (2015). Anatomy of the veno- muscular pumps of the
lower limb. Phlebology 30 (3): 180–193.
Williams, K.J., Ayekoloye, O., Moore, H.M., and Davies, A.H. (2014). The
calf muscle pump revisited. Journal of Vascular Surgery: Venous and
Lymphatic Disorders 2 (3): 329–334.
Wounds UK (2016). Best practice statement: Holistic management of venous
leg ulceration. https://wounds- uk.com/best- practice- statements/
holistic- management- of- venous- leg- ulceration
Yang, D., Vandongen, Y.K., and Stacey, M.C. (1999). Eect of exercise on calf
muscle pump function in patients with chronic venous disease. British
Journal of Surgery 86 (3): 338–341.
Hammarlund, C.S., Andersson, K., Andersson, M. etal. (2014). The signi-
cance of walking from the perspective of people with Parkinson’s dis-
ease. Journal of Parkinson’s Disease 4 (4): 657–663.
National Institute for Health and Care Excellence (NICE) (2019). Falls risk
assessment. https://cks.nice.org.uk/topics/falls- risk- assessment
muscle system of the foot and of the
elastic
本书版权归John Wiley & Sons Inc.所有
Musculoskeletal Factors in Leg Ulcers 225
https://t.me/medicina_free
National Wound Care Strategy (2023). Data collection form for CQUIN Audit
CCG13. Assessment, diagnosis, and treatment of lower leg wounds
(v4.1). https://www.nationalwoundcarestrategy.net/cquin
Nigg, B.M., Federolf, P., and Landry, S.C. (2010). Gender dierences in lower
extremity gait biomechanics during walking using an unstable shoe.
Clinical Biomechanics 25 (10): 1047–1052.
Oce for Health Improvement and Disparities (2022). Falls; applying
All Our Health. https://www.gov.uk/government/publications/fallsapplying- all- our- health/falls- applying- all- our- health
本书版权归John Wiley & Sons Inc.所有
CHAPTER
https://t.me/medicina_free
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
本书版权归John Wiley & Sons Inc.所有
Assessment of Leg Ulceration 227
https://t.me/medicina_free
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,
本书版权归John Wiley & Sons Inc.所有
228 ASSESSMENT OF LEG ULCERATION
https://t.me/medicina_free
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.
本书版权归John Wiley & Sons Inc.所有
Assessment of Leg Ulceration 229
https://t.me/medicina_free
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.
本书版权归John Wiley & Sons Inc.所有
230 ASSESSMENT OF LEG ULCERATION
https://t.me/medicina_free
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
本书版权归John Wiley & Sons Inc.所有
Assessment of Leg Ulceration 231
https://t.me/medicina_free
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
本书版权归John Wiley & Sons Inc.所有
Соседние файлы в папке Библиотека им академика М.И. Перельмана